Lindsay Thomson

The State Hospital survey: A description of psychiatric patients in conditions of special security in Scotland

Abstract The State Hospital, Carstairs, is the maximum security psychiatric facility for Scotland and Northern Ireland. This study describes the cohort of patients there (N = 241) between 1992 and 1994. Case-notes were examined to ascertain demographic details and information on psychiatric, medical, drug, forensic, family and personal histories. Diagnoses were made by application of the St Louis criteria (Feighner et al 1972). Standardized interviews were held with each patient and the responsible medical officer. Patients were on average 34 years old and had spent 9 years in psychiatric hospitals. There were 169 (70.1%) who had a principal diagnosis of schizophrenia. Approximately half were admitted following an offence and over 80% had a history of criminal activity. Physical health problems were present in more than 50% of patients. Adverse childhood events of diverse kinds were frequently reported. Psychotic symptoms continued to occur in many patients despite extensive treatment. More than half were...

PREDICTING RECIDIVISM BY MENTALLY DISORDERED OFFENDERS USING THE LSI-R:SV

The Level of Service Inventory—Revised: Screening Version (LSI-R:SV) has proven to validly predict reoffending in general offender populations but has not previously been studied specifically with offenders who have a major mental illness, including those with a dual diagnosis. This research project measures the validity of the LSI-R:SV for use with 208 mentally ill offenders who were released from a secure forensic hospital in Melbourne, Australia. Results indicate that the LSI-R:SV is a good predictor of recidivism among mentally disordered offenders. However, the LSI-R:SV does not reliably predict recidivism in individuals who attracted a dual diagnosis. Further research needs to reevaluate risk factors associated with recidivism in offenders with a dual diagnosis.

Factors associated with seclusion in a statewide forensic psychiatric service in Australia over a 2-year period

Despite seclusion being described as one of the most ethically- and legally-controversial management options available, it remains a widely-used clinical strategy for managing disruptive, aggressive, and violent behaviour. This study sought to determine how frequently seclusion was used, the common characteristics of those secluded and not secluded, and the degree to which the Level of Service Inventory - Revised: Screening Version (LSI-R: SV) could predict seclusion. The study was retrospective, covering the first 2 years of operation of a statewide forensic psychiatry hospital in Victoria, Australia. Data were collected from individual case files, electronic databases, and paper copies of records pertaining to violent incidents and episodes of seclusion. Eighty five (44%) of the 193 patients admitted during this period were secluded. Those secluded were significantly younger and had a more established psychiatric history. LSI-R: SV scores were significantly and positively associated with being secluded. A statistical model containing three LSI-R: SV items, along with age on admission and psychiatric history, achieved an area under the curve of 0.74. Seclusion is used on a regular basis in response to a range of different forms of aggressive behaviour of different severity. The LSI-R: SV demonstrated moderate-to-good accuracy in predicting seclusion and warrants further research using detailed prospective methodologies.

Appropriate treatment targets or products of a demanding environment? The relationship between aggression in a forensic psychiatric hospital with aggressive behaviour preceding admission and violent recidivism

Abstract Effective treatment of aggressive behaviour and accurate release decision making are necessary components of adequate clinical practice in forensic psychiatric units. Unfortunately, methods to identify treatment targets and ameliorate aggressive behaviour have developed at a slower pace than risk assessment technologies. Recent progress on the identification of offence paralleling or functionally equivalent behaviour offers a framework for individually tailored treatment and idiographic release decision making, although empirical scrutiny of this approach is inadequate. This paper describes an examination of the relationship between aggressive behaviour prior to admission with aggression during inpatient psychiatric treatment, and reconviction for violent offending following discharge. Results showed a relationship between pre- and post-admission aggression but no relationship between aggression during inpatient psychiatric treatment with either pre-admission aggressive behaviour or violent recidivism. These findings indicate the importance of state psychological variables, specifically those states affected by symptoms of psychiatric illness, as well as environmental activators and inhibitors of violence that operate within the hospital. These require inclusion in an adequate functional analysis of aggressive behaviour for forensic psychiatric patients.

Risk Assessment in Forensic Patients with Schizophrenia: The Predictive Validity of Actuarial Scales and Symptom Severity for Offending and Violence over 8 – 10 Years

Assessment of risk of violence is essential in the management of patients with schizophrenia admitted to secure hospitals. The present study was conducted to test the validity of actuarial measures and psychotic symptoms in the prediction of further violence and offending in this group. The H-10 scale of the HCR-20, Violence Risk Appraisal Guide and Psychopathy Checklist-Revised were scored retrospectively. Symptom severity was rated at interview and persistence from notes. Outcome was measured using criminal records and recorded incidents of aggression over an 8-10 year period. Seventy-six percent of patients were involved in more than 1800 incidents defined as physical contact with a victim or damage to property, and 28% in a serious incident defined as injury to a victim requiring hospital treatment, a contact sexual incident or fire setting. Fifteen percent of patients were convicted of any offense and 5% of a violent offense. The risk scales had moderate to high predictive accuracy for offenses and violent offenses but failed to predict incidents or serious incidents. Symptom severity and persistence predicted incidents but not offenses. Violence within this population is common. Actuarial measures of risk assessment are valid predictors of offending and violent offending but psychotic symptoms are more relevant to the prediction of violent incidents. Assessments of likely inpatient aggression must emphasize symptoms.

Violence risk assessment: the use of the PCL-SV, HCR-20, and VRAG to predict violence in mentally disordered offenders discharged from a medium secure unit in Scotland

Risk assessment tools are increasingly used in the management of mentally disordered offenders in Scotland, but there has been limited research into their validity among this population. The aim of this study was to examine the validity of risk assessment tools in predicting violence following discharge from a Scottish medium secure unit. The PCL-SV, the VRAG, and the historical subset of the HCR-20 were completed on 96 patients. Follow-up information regarding post-discharge violence and clinical factors was collected for two years. Four (4.2%) patients from the sample committed five serious violent offences, while 38 (40.6%) patients committed more than 100 minor violent offences. The risk assessment tools were found to have moderate predictive accuracy for violent outcomes. Thus this study provides useful evidence supporting the validity of risk assessment tools in Scotland. Individual clinical factors such as substance abuse, personality disorder, treatment non-compliance, and symptom relapse are also relevant in risk assessment and management.

Assessing Risk for Aggression in a Forensic Psychiatric Hospital Using the Level of Service Inventory-Revised: Screening Version

The assessment of risk for aggression has become a central concern of many mental health services. Some structured schemes for guiding risk assessment, developed primarily to assess risk in psychiatric patients discharged from hospital and offenders being considered for release from prison, have recently been trialled in the inpatient setting. Against the background of some prior research demonstrating the potential benefits of structured assessment schemes, and some concerns about the practicality of these schemes for assessing risk in inpatients, the current research was initiated to assess the effectiveness of the Level of Service Inventory-Revised: Screening Version (LSI-R: SV) in the prediction of aggression within a forensic psychiatric hospital. Results showed that only a weak association between the LSI-R: SV total score and inpatient aggression existed. This is probably because the LSI-R: SV addresses more static variables and does not assess the clinical characteristics and recent hostility that is associated with aggression in psychiatric patients. The predictive validity of the LSI-R: SV in this context is therefore limited. There might be more effective schemes, some of which were designed specifically for the purpose of assessing inpatient aggression that should be used in preference to the LSI-R: SV.

Substance dependence and schizophrenia in patients with dangerous, violent and criminal propensities : A comparison of co-morbid and non-co-morbid patients in a high-security setting

Studies show that schizophrenia is associated with increased substance misuse/dependence. An association exists between co-morbidity and violence/offending. Our aim was to compare substance-dependent and non-substance-dependent patients with schizophrenia, by using patient interviews and retrospective case-note data. A sample of 169 patients with schizophrenia in high-security psychiatric care was divided into two groups by using the absence/presence of substance dependence. Diagnoses were made using St Louis criteria. Of the patients, 88.8% were male. Lifetime rates of substance misuse showed that 53.8% had a history of alcohol misuse and that 53.3% had a history of drug misuse. Co-morbid substance dependence was present in 41.4% and schizophrenia alone in 58.6%. Co-morbid patients were more likely to be from the west of Scotland, to have a history of convictions and to be intoxicated prior to admission. They were more likely to be treated with anti-cholinergics or anti-depressants, to suffer affective symptoms or to have anti-social personality disorder. They were less likely to have negative symptoms, thought disorder, or learning disability and less likely to be civilly detained. This study finds high rates of substance misuse/dependence occurring co-morbidly with schizophrenia in Scottish high-security settings. Co-morbidity is associated with increased offending. Differences in symptom profiles and demographics may have potential implications for recognition and risk management.

The assessment of imminent inpatient aggression: a validation study of the DASA-IV in Scotland

Inpatient aggression in psychiatric settings poses a serious management problem. This study reports the findings of a prospective pilot study on the Dynamic Appraisal of Situational Aggression – Inpatient Version (DASA-IV), a structured risk assessment tool for imminent aggression. The study was conducted in the State Hospital, the high secure psychiatric hospital for Scotland and Northern Ireland. The outcome data were aggressive incidents recorded on the Staff Observation Aggression Scale – Revised (SOAS-R) and incidents noted on the hospitals online recording tool. All measures were completed by nursing staff as part of their daily clinical routine to ensure ecological validity. The DASA-IV was found to be of moderate to good predictive power. Limitations and suggestions for further research are outlined, and the potential for implementation of the tool is discussed.

The predictive validity of the HCR-20 following clinical implementation: does it work in practice?

This prospective study describes the predictive validity of the Historical Clinical Risk Management-20 Scale (HCR-20) when applied to clinical practice among 109 male mentally disordered offenders in a high secure forensic hospital. Data on violent incidents including reconvictions were collected from multiple sources. The results imply that the implemented HCR-20s did not predict future violence regardless of setting (community vs inpatient) nor time (short vs long term) except for serious incidents. This may indicate that the implemented HCR-20s informed risk management through systematic tailoring of care and treatment plans. Evidence supporting this interpretation was found in a reduction in violent incidents and offending when compared to an earlier study with a similar cohort. Alternatively, the completion of a violence risk assessment by clinicians rather than researchers may have affected the quality of completed assessments. Further research is required to better understand the complex mechanisms underlying the translation of identified risk factors into risk management.