Lesley Sutton

A systematic review of outcome measures used in forensic mental health research with consensus panel opinion.

OBJECTIVE To describe and assess outcome measures in forensic mental health research, through a structured review and a consensus panel. DATA SOURCES A search of eight electronic databases, including CINAHL, EMBASE and MEDLINE, was conducted for the period 1990-2006. REVIEW METHODS In the structured review, search and medical subject heading terms focused upon two factors: the use of a forensic participant sample and the experimental designs likely to be used for outcome measurement. Data extraction included general information about the identity of the reference, specific information regarding the study and information pertaining to the outcome measures used. The consensus exercise was implemented in two stages. At the first stage, participants were asked to complete ratings about the importance of various potential areas of outcome measurement in a written consultation. At the second stage, they were asked to attend a consensus meeting to review and agree results relating to the domains, to consider and rate specific outcome instruments identified as commonly used from the structured review and to discuss strengths, weaknesses and future priorities for outcome measurement in forensic mental health research. RESULTS The final sample of eligible studies for inclusion in the review consisted of 308 separate studies obtained from 302 references. The consensus group agreed on 11 domains of forensic mental health outcome measurement, all of which were considered important. Nine different outcome measure instruments were used in more than four different studies. The most frequently used outcome measure was used in 15 studies. According to the consensus group, many domains beyond recidivism and mental health were important but under-represented in the review of outcomes. Current instruments that may show future promise in outcome measurement included risk assessment tools. The outcome measure of repeat offending behaviour was by far the most frequently used, occurring in 72% of the studies included in the review. Its measurement varied with position in the criminal justice system, offence specification and method of measurement. The consensus group believed that recidivism is only an indication of the amount of antisocial acts that are committed. CONCLUSIONS A wide range of domains are relevant to assessing outcomes of interventions in forensic mental health services. Evaluations need to take account of public safety, but also clinical, rehabilitation and humanitarian outcomes. Recidivism is a very high priority; the public expects interventions that will reduce future criminal behaviour. Greater attention needs to be given to validity of measurement, given the enormous variety of approaches to measurement. More research is needed on methods to take account of the heterogeneity of seriousness of forms of recidivism in outcome measurement. Validity of self-report instruments regarding recidivism also needs examination by further research. Mental health is clearly also an important dimension of outcome. The review provides clear support for the view that domains such as quality of life, social function and psychosocial adjustment have not been extensively employed in forensic mental health research, but are relevant and important issues. The role of such instruments needs more consideration.

Outcome measures used in forensic mental health research: a structured review

BACKGROUND The evidence base for forensic mental health (FMH) services has been developing since the late 1990s. Are outcome measures sound enough for the evaluation tasks? AIMS To identify, from published literature, outcome measures used in FMH research and, where feasible, assess their quality. METHOD A structured review was undertaken of trials and intervention studies published between 1990 and 2006. Details of outcome variables and measures were abstracted. Evidence regarding most frequently occurring outcome measures was assessed. RESULTS Four hundred and fifty different instruments were used to assess outcomes, incorporating 1038 distinct variables. Very little evidence could be found to support the measurement properties of commonly used instruments. CONCLUSIONS and implications for practice There is little consistency in the use of outcome measure in FMH research. Effort is required to reach consensus on validated outcome measures in this field in order to better inform practice.

Suicide by gunshot in the United Kingdom: a review of the literature.

This paper reviews the research literature on gunshot suicide in the United Kingdom and the international literature with reference to strategies aimed at preventing gunshot suicides. Trends in gun ownership and changes in firearm legislation in the UK over the past 20 years are described. Most UK gunshot suicides are male, middle-aged and living with a partner and involve the use of shotguns. They are less likely to have current or past mental health problems, or a previous act of self-harm, than people who commit suicide by other methods, and their suicide is more likely to have been precipitated by a relationship dispute. Where alcohol is consumed the amount tends to be large. The international literature provides evidence of a strong association between rates of gun ownership and gunshot suicide, and some evidence of a reduction in firearm suicide rates following the introduction of restrictive firearm legislation. Over the past 20 years the number of gunshot suicides in the UK has declined by over 50% to a little over a hundred deaths per annum. At the same time, firearm legislation has become progressively more restrictive and rates of gun ownership have declined. Measures, which might further reduce the prevalence of gunshot suicides in the UK, are discussed.

Gunshot suicides in England--a multicentre study based on coroners' records.

BackgroundGunshot suicides account for 2.5% of suicides in England and Wales. This amounts to more than 100 deaths per year. Information about such deaths may assist in the development of suicide prevention strategies.MethodWe have examined coroners’ inquest records for all gunshot suicides between 1st January 2000 and 31st December 2001 in 24 coroners’ jurisdictions in England.ResultsFifty-eight gunshot suicides were identified, including one homicide-suicide. Ninety-three per cent of cases were male. Sport or occupational usage was the main reason for owning the gun. Ten per cent were farmers or farm-workers. In 20% of cases the gun did not belong to the individual who used it for suicide. This was more likely in younger suicides. Seven (12.1 %) individuals used illegally owned handguns. Large amounts of alcohol had been consumed before the act in nine cases. Nearly three-quarters (72.9%) of individuals with diagnostic information had a probable diagnosis of depression. However, only 22.4% had ever had contact with psychiatric services. Two shotgun certificate holders were under the care of psychiatric services at the time of their death and two others had a history of previous self-harm.ConclusionsStrategies to reduce the number of gunshot suicides need to focus on limiting access to guns. These include restricting access to guns by non-certificate holders and those who may be at increased risk of suicide, and holding regular gun amnesties.

Outcome measurement in forensic mental health research: an evaluation

Abstract Measuring change resulting from healthcare interventions is critical to evaluating their usefulness. The choice of outcome measure is an important part of such evaluations and is driven by assumptions about what is likely to change and how best to capture this. Despite its importance, forensic mental health has paid little attention to determining which are the best measures of outcome. This study used a panel of relevant professionals to (i) assess the relative importance of different areas of potential outcome measurement and (ii) evaluate specific instruments used currently as outcome measures in forensic mental health research. Although a wide range of potential outcomes were endorsed as appropriate, few corresponding instruments have been used consistently. Only three psychiatric instruments deemed by our panel as feasible, relevant and psychometrically adequate have been used in five or more studies (the Beck Depression Inventory; the Brief Psychiatric Rating Scale, and the Symptom Checklist-90–Revised). Significant measurement gaps were noted in areas such as social and emotional functioning. Although instruments exist that could capture most areas, none were sufficiently developed for routine use as outcomes. Further research to develop robust, sensitive and diverse outcome measures is needed. This is an essential precursor to extending the evidence base for forensic mental health interventions.