Nadji Kahtan

Elderly patients admitted to secure forensic psychiatry services

In a study of admissions to medium- and high-security from 7 of 14 health regions over a 7-year period, less than 2% were aged 60 years or over. These patients were atypical and highly selected, and half had committed homicide. Depressive illness, delusional disorder and dementia were the most prevalent diagnoses. The patients aged 60 and over had fewer previous convictions than younger patients, and were older when first admitted to psychiatric hospitals, usually in the context of their offending behaviour. The study suggests that some admissions to specialist services reflect an absence of more suitable provision for elderly patients at a lower level of security. Forensic psychiatry services were not involved with the growing number of elderly prisoners who are serving longer prison sentences and the needs of this group require further study.

Women admitted to secure forensic psychiatry services: II. Identification of categories using cluster analysis

It has been recommended that there should be new therapeutic regimes for women who need secure inpatient services. Cluster analysis was applied to the diagnoses of 471 women admitted to Special Hospitals and medium secure units over a 7-year period from a geographically representative area of seven health regions in the UK. The aim was to identify categories that may facilitate the development of new specialist services. A seven-cluster solution revealed three subgroups of women with personality disorder as their primary psychopathology, three with major mental illness, and one with organic brain syndrome. Each may require different therapeutic regimes and levels of inpatient security. Further research is necessary to determine whether any single category could be managed in specialist facilities without recourse to high perimeter security. High security will continue to be needed for women with anti-social personality disorder.

Are Special Hospitals needed

It has been recommended that the Special Hospitals should be replaced by high-security services at a regional level. This study examines the implications of such a change in policy and demonstrates that local facilities would have to contain a significant proportion of patients whose violent and criminal behaviour cannot be managed in medium security and where in some cases all previous therapeutic interventions have failed to prevent a progression through successively higher levels of hospital security over time. Admissions to Special Hospitals followed more serious behavioural disturbance in other psychiatric services and more serious offences; the patients had more extensive previous criminal histories and were more likely to have primary and comorbid diagnoses of personality disorder and paraphilias. Almost a quarter of all admissions to the Special Hospitals in 1988–94 were transfers from medium security. This study provides little evidence that medium-security services reduced the demand for beds in Special Hospitals over the study period. The transfer of high-security beds to local services would have to take into account the threefold difference in levels of demand across regional catchment areas.

An instrument to measure the security needs of patients in medium security

The paper describes a four-point scale to measure the level of security required by patients in medium security. The scale was retrospectively applied to case-notes for 3,396 admissions to medium security over a 7-year period from a defined geographical area of England. Preliminary findings suggest satisfactory content validity and that the four-level rating system successfully discriminates between admissions according to four levels of security. Further research is required on the reliability of the instrument and to demonstrate whether the scale can be used as a proxy measure for the burden of care imposed by admissions to medium secure services.

Psychiatric diagnosis and differential risks of offending following discharge

Psychiatric diagnosis is not considered a risk factor for offending following discharge. However, treatment interventions and aftercare are strongly influenced by clinical primary diagnosis. We compared differential risks of reoffending of patients falling into six primary diagnostic categories following discharge from Medium Secure Units in the UK: schizophrenia/schizoaffective disorder; delusional disorder; mania/hypomania; depressive disorder; organic brain syndrome; personality disorder. We followed up 1344 patients, on average 6.2 years (SD=2.1) at risk, discharged from 7 of 14 Regional Medium Secure services in England and Wales. Outcomes were period prevalence, incidence, and cumulative probability of criminal conviction. Established demographic and criminal history predictors of reoffending were observed across different diagnostic categories. Risks of all offending were increased for personality disorder, violence/acquisitive offending for delusional disorder, sexual offending for mania/hypomania and violence/acquisitive offending for organic brain syndrome. Patterns of risk over time differed markedly between categories of mental disorder. Most patients with personality disorder who offended violently did so within 4 years of discharge. A subgroup with delusional disorder demonstrated increased risk of violent offending 5 years after discharge. Differential risks of reoffending are observed between different diagnostic groups. Clinical diagnosis should be included together with established risk measures in risk management following discharge. Close supervision of patients with personality disorder should begin immediately after discharge when risks of reoffending are greatest. For delusional disorder further investigation is needed into the marked increase in risk of violence after 5 years.