Rajan Darjee

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.

New mental health legislation

Scottish legislation, based on “care and treatment,” has lessons to offer

Substance misuse in a high security hospital: Three years of urine drug testing at the State Hospital, Carstairs

With the increasing evidence for the significant contribution to violence made by alcohol and drug misuse in people with mental disorder, there is emerging evidence of the importance and increasing prevalence of substance misuse problems in patients admitted to high security hospitals in the UK. Recorded routine voluntary urine drug screening of patients at the State Hospital, the high security hospital for Scotland and Northern Ireland, started in 1998. Results of urinalysis over the 3 years from 1 January 1999 to 31 December 2001 were examined. Out of 7,069 samples sent from 421 patients there were 712 (10.1%) positive results. The majority were false positives (672; 9.5%) due to prescribed medication, with only 40 (0.6%) true positives. All the true positive results in the admission unit were related to substance misuse prior to admission, the remaining true positive results were all within the continuing care wards, with no true positives in the rehabilitation wards. Even though the testing was not truly random, it is likely that the findings reflect extremely low levels of substance misuse within the hospital in contrast with findings from UK prisons. Whether urine testing contributes to the prevention of drug misuse within the hospital is unclear, and there are potential ethical and legal concerns about the urine testing process. It is important that high security hospitals are virtually drug free, to enable the uncontaminated assessment and treatment of mentally disordered offenders.

A demographic study of the Orchard Clinic: Scotland's first medium secure unit

Forensic services in Scotland are evolving, based on similar developments previously in England and Wales. The Orchard Clinic in Edinburgh is the first medium secure unit to open in Scotland. This paper aims to describe the patients admitted to the unit in the first five years of its operation, to consider antecedents to their admission, patient characteristics and progress through the system. With the development of a new service it is important to benchmark against established services and, therefore, a comparison is made with earlier studies of forensic populations in Scotland and elsewhere in the UK.

Professionalizing the role of appropriate adults

Abstract The role of an appropriate adult (AA) is to facilitate communication, to ensure an understanding of legal rights, and to provide support for an individual with a mental disorder at police interview. Such schemes differ significantly throughout the UK in terms of legal basis, requirements to be an AA, and client group. This study provides the first description of AA schemes in Scotland, and makes recommendations relevant to Scotland and wider jurisdictions. By 2002 all of Scotland had access to the services of appropriate adults via 16 schemes. This study identified problems with lack of record-keeping, performance indicators, standardized procedures, and management structures, and also with under-utilization and knowledge gaps in AAs and related professions. Police interviews have been ruled inadmissible because of lack of an AA, and also failure of an AA to explain legal rights. Recommendations are made: to create standardized reporting and training systems under the control of an umbrella organization; to develop the role of AAs through a mandatory professional background related to mental health and specific training in relevant legal matters; to develop a more realistic definition of mental disorder requiring the services of an AA with established procedures to assist police officers in their identification; to place the AA schemes in Scotland on a statutory basis; and to establish a framework for AAs to fulfil their role within a court setting.

Crime and Punishment (Scotland) Act 1997: a survey of sentencers' views concerning the Scottish 'hybrid order'.

The Crime and Punishment (Scotland) Act 1997 introduced the hospital direction (HD), often termed the ‘hybrid order’ because it allows courts to simultaneously send a mentally disordered offender to hospital and impose a prison sentence, to be completed after hospital discharge. It is the first measure that explicitly allows the imposition of a prison sentence for an offender meeting criteria for detention under the Mental Health (Scotland) Act 1984. A previous survey showed that psychiatrists in Scotland favoured the principle of a hybrid order (Darjee et al., 2000). In this study all Scottish Sheriffs (n=110) and High Court Judges (n=26) were surveyed for their views on the HD. Of the 56 respondents 19 felt unable to participate largely due to lack of experience in sentencing mentally disordered offenders. Respondents felt the HD was a useful measure, but, in contrast to Scottish Office guidance, indicated that psychiatrists should recommend it directly if they considered that it was an appropriate disposal. Respondents viewed the HD as primarily an incapacitating measure and most respondents hoped that it would encourage psychiatrists to admit ‘psychopaths’ although Scottish psychiatrists do not favour the hospitalisation of offenders with primary personality disorders. It is concluded that in its current form and with current guidance the HD is difficult to use, as there are no criteria to differentiate it from a hospital order (HO) and psychiatrists cannot recommend it. Further, recent legislation that makes public safety the primary concern when deciding on the discharge of restricted patients in Scotland, erodes the utility of the HD as an incapacitating measure. However following the Reports of the Millan and MacLean Committees in Scotland, the role of the HD may be strengthened and clarified.

Reid v. the United Kingdom : Restricted patients and the European Convention on Human Rights

This article describes the recent decision of the European Court of Human Rights in the case of a patient with personality disorder detained under a restriction order in Scotlands high security hospital. This is set in the context of recent case law in Scotland in similar cases and in England where forensic patients have made challenges, in domestic courts under the European Convention on Human Rights (ECHR), to their detention and treatment. We conclude that the ECHR has offered little in the way of tangible benefit to such patients.

Sexual and Nonsexual Homicide in Scotland: Is There a Difference?:

While a number of previous studies have compared sexual homicides to nonlethal sexual offenses, there have been few studies comparing sexual and nonsexual homicides. This study examines whether sexual homicide offenders differ from nonsexual homicide offenders in Scotland regarding characteristics of the offender, the victim, and the homicide incident. Unlike previous studies, only homicides committed by males against females were examined. Data from a national police database were used to compare 89 male sexual homicide offenders who killed adult females with 306 male nonsexual homicide offenders who had also killed adult females using bivariate and multivariate (logistic regression) analyses. The findings revealed not only some similarities between the two groups, particularly regarding some victim variables, but also significant bivariate and multivariate differences. Sexual homicides appeared to be associated with indicators of instrumentality and sexual deviance. We conclude that sexual homicide offenders might be considered a distinct group of homicide offenders, more similar to sexual offenders than to other homicide offenders.

Female Sexual Homicide Offenders: A Descriptive and Comparative Study

Research on female sexual homicide has been very scarce. In Europe, it has rarely been examined, and in Scotland, it has never previously been studied. This exploratory study aims to examine the characteristics of sexual homicides involving female offenders between 1990 and 2015 in Scotland. Using data from the Scottish Homicide Database between 1990 and 2015, female sexual homicides (n = 7) were compared to nonsexual homicides committed by females (n = 106) and to sexual homicides committed by men (n = 89) using Fishers exact tests. The findings show that although female sexual homicide offenders are similar to both female nonsexual homicide offenders and male sexual homicide offenders in certain aspects, there are important differences that distinguish sexual homicides involving female offenders from both groups. Female sexual homicide offenders can arguably be seen as a distinct group of offenders, with specific characteristics and specific needs.