Anthony Samuels

Suicide in New South Wales Prisons, 1995–2005: towards a better understanding

Objectives: This paper reports on a review of suicides in New South Wales (NSW) prisons from 1 January 1995 to 31 December 2005 in an attempt to gain a better understanding of the nature and quality of the problem of suicide among prisoners. Method: All deaths in NSW prisons for the period were reviewed. Those identified as self-inflicted, with a coronial finding of death by suicide or those awaiting a coronial hearing but reported as possible death by suicide were included. A data set was collected on each case and entered into a database. Results: A total of 92 cases were identified as deaths by suicide in NSW prisons from 1 January 1995 to 31 December 2005, representing 41% of all deaths in custody for the period. Conclusion: The rate of suicide in NSW prisons has been declining over the past 10 years, but remains approximately 10-fold that of the NSW community. Suicide was the leading cause of death among NSW inmates from 1995 to 2005. Suicide is a rare event, making its prediction a difficult task, with the prison environment a further compounding factor. This review highlights a number of factors, which appear to be common in many cases. Increased monitoring during the first week of incarceration may be an effective intervention. It is recommended that consideration be given to the length of time spent on remand and the value of custodial sentences of ≤6 months.

Pursuit of the perfect mother: an unusual case of stalking

Objective: To highlight issues of adoption and twinship in an unusual case of stalking. Clinical picture: An ususual case of same gender, serial stalking which began at an early age in a young woman who was one of a set of twins adopted at birth. Treatment: Insight orientated psychotherapy. Outcome: Beneficial outcome in context of clear boundaries, therapist selection and emphasis upon legal consequences of behaviour. Conclusions: Early disruptions to attachments including adoption and twinship may have relevance in some patterns of adult stalking behaviour.

The harassment and stalking of plastic surgeons by their patients in Australasia

Medical professionals come into direct contact with the public. The relationships are often personal. The aim of the survey is to examine the prevalence of harassment of plastic surgeons by their patients.

Defining the personality disorders: description of an Australian database.

Objective: We seek to improve the definition and classification of the personality disorders (PDs) and derive a large database for addressing this objective. Method: The paper describes the rationale for the development of a large set of descriptors of the PDs (including all DSM-IV and ICD-10 descriptors, but enriched by an additional 109 items), the design of parallel self-report (SR) and corroborative witness (CW) measures, sample recruitment (of 863 patients with a priori evidence of personality disorder or disturbance) and preliminary descriptive data. Results: Analyses (particularly those comparing ratings on molar PD descriptions with putative PD dimensions) argue for acceptable reliability of the data set, while both the size of the sample and the representation of all PD dimensions of interest argue for the adequacy of the database. Conclusions: We consider in some detail current limitations to the definition and classification of the PDs, and foreshadow the analytic techniques that will be used to address the key objectives of allowing the PDs to be modelled more clearly and, ideally, measured with greater precision and validity.

When killing isn't murder: psychiatric and psychological defences to murder when the insanity defence is not applicable

Objective: This paper describes psychiatric and psychological defences to murder where the defence of insanity is not applicable. The charges of murder and manslaughter are outlined. Self-defence, sane and insane automatism, provocation, diminished responsibility, duress, necessity and novel defences are discussed. Conclusions: The complexities of psychological and psychiatric expert evidence are highlighted as well as the fact that legal decisions are not always consistent with medical or scientific theory. It is concluded that this is a controversial and evolving area of mental health law and mental health professionals have an educative role and a responsibility to provide testimony that is supported by the best possible evidence.

Clozapine use in a forensic population in a New South Wales prison hospital

Objective: To document and measure various parameters and outcomes in patients prescribed clozapine in a forensic psychiatric setting. Method: A retrospective file review was conducted on patients prescribed clozapine. Parameters and outcomes were recorded and compared against a group prescribed other antipsychotics, matched for sex and diagnosis. Results: Patients prescribed clozapine had higher rates of substance misuse syndromes and comorbidity when compared to patients prescribed other antipsychotics. Clozapine was found to be effective in treatment of psychosis. High rates of adverse effects were noted. Discontinuation of clozapine for a variety of reasons was common. Conclusion: Patients identified as treatment resistant who are prescribed clozapine are often more complex in the pattern of illness and subsequent needs. Clozapine is effective in the treatment of psychosis in this forensic service. Its benefits need to be balanced against the potential for adverse effects and problems ensuring adherence. Regular, objective monitoring of clinical and adverse effects would aid patient safety, clinical decision-making and future research.

Fitness Issues in the Context of Judicial Proceedings

Objective: This paper provides a conceptual, historical and legislative overview of fitness issues. These include fitness to be interrogated or charged, to plead, to be tried and to be sentenced in the context of Australia and New Zealand. Conclusions: Legislation regarding fitness issues needs to strike a balance between protecting the rights of mentally impaired defendants to a fair trial process and recognizing that mental illness in itself does not absolutely preclude participation in a trial process or necessarily diminish criminal responsibility. Although the key determinants of fitness seem to be the ability to cope with court processes and communicate with counsel, the application of clinical judgement to legal criteria is not always straightforward.

Clinical Practice Issues in Consultation-Liaison Psychiatry:

Objective: To overview and highlight the issues currently challenging and confronting consultation-liaison (C-L) psychiatry and to present them for discussion in a wider forum. Method: Following preliminary discussions, the authors (members of the New South Wales C-L Interest Group) undertook to selectively review a number of issues relevant to C-L psychiatry. A preliminary paper was prepared and then presented to the membership of the interest group. Feedback from this meeting was incorporated into the final version of the paper. Results: Issues selected as a nidus for further discussion include economic issues, changing models of C–L practice, service issues as well as ethical issues. In addition, recognition of C–L psychiatry as a true subspeciality is foreshadowed. Conclusion: This paper highlights some of the challenges for C–L psychiatry both now and in the future. Intuitive beliefs in our efficacy will not suffice in this era of economic rationalisation. Disciplined and focused research substantiating our value is imperative. Subspecialty recognition is likely to ensure uniformity of standards as well as providing the structure and direction required to consolidate C–L psychiatrys future.

Civil forensic psychiatry – Part 2: specific issues:

Objectives: This paper describes the main areas of civil forensic psychiatry (FP) and the skills required by psychiatric experts. Some specific areas of civil FP are discussed, including tort law reform, reliability of psychiatric evidence, contentious psychiatric disorders, and the many domains of civil FP. Conclusions: Civil FP is an important sub-specialty component of forensic psychiatry that requires greater emphasis in the training and continuing education of psychiatrists. A process of accrediting psychiatrists as having competency in advanced civil FP may be of value.

Civil Forensic Psychiatry – part 3: practical aspects of managing a medico-legal practice:

Objectives: This is the third in a series of papers on Civil Forensic Psychiatry and provides practical advice for forensic psychiatrists, general psychiatrists and trainees who are expanding or contemplating a medico-legal aspect to their practice. Conclusions: Attention to the practice setting, office layout, recording of information, management of documentation, screening of briefs and proper timetabling can improve safety, quality, reliability and workload manageability.