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The recall of conditionally discharged forensic patients in England is a formal order from the Ministry of Justice under the Mental Health Act (1983) which has the power to revoke conditional release and direct readmission to hospital. Recall has significant implications for the individual and for hospital services, but despite this, little is known about predictors of recall for forensic patients.
We examined the rate of recall for 101 patients conditionally discharged from medium secure forensic inpatient services between 2007 and 2013. Demographic, clinical, and forensic factors were examined as possible predictors of time to recall using Cox regression survival techniques.
Conditionally discharged patients were followed for an average of 811 days, during which 45 (44.5%) were recalled to hospital. Younger age (HR 1.89; 95% CI 1.02–3.49; p = 0.04), non-white ethnicity (HR 3.44; 95% CI 1.45–8.13), substance abuse history (HR 2.52; 95% CI 1.17–5.43), early violence (HR 1.90; 95% CI 1.03–3.50), early childhood maladjustment (HR 1.92; 95% CI 1.01–3.68), treatment with a depot medication (HR 2.17; 95% CI 1.14–4.11), being known to mental health services (HR 3.44; 95% CI 1.06–11.16), and a psychiatric admission prior to the index admission (HR 2.44; 95% CI 1.08–5.52) were significantly associated with a shorter time to recall. Treatment with clozapine reduced the risk of recall to hospital (HR 0.40; 95% CI 0.20–0.79).
Time to recall can be predicted by a range of factors that are readily available to clinical teams. Further research is required to determine if targeted interventions can modify the likelihood or time to recall for conditionally released forensic patients.
This chapter describes the classical subtypes, differential diagnosis, epidemiology and genetics of schizophrenia and related disorders. Relatives are examined for some of the biological abnormalities which are found in their schizophrenic kin. The relatives of patients with schizophrenia have also been reported to be more likely than control subjects to have poor performance on cognitive tests measuring memory functions. The discovery of risk factors acting in early life has been central to the neurodevelopmental hypothesis of schizophrenia. Magnetic resonance imaging (MRI) studies have consistently demonstrated that people with schizophrenia have increased lateral ventricular volume and also show a slight decrease in cortical volume with greater decrements in the hippocampus, amygdala and thalamus. Children destined to develop schizophrenia often have subtle developmental delays and deficits in motor and cognitive function, tend to be solitary and show an excess of social anxiety. The chapter reviews the essential principles of management for psychosis.
A limited case-load size is considered crucial for some forms of
intensive case management and many countries have undertaken extensive
reorganisation of mental health services to achieve this. However, there
has been limited empirical work to explore this specifically.
To test whether there is a discrete threshold for changes in intensive
case management practice determined by case-load size.
‘Virtual’ case-load sizes were calculated for patients from their actual
contacts over a 2-year period and were compared with the proportions of
contacts devoted to medical and non-medical care (as a proxy for a more
comprehensive service model).
There were 39 025 recordings for 545 patients over 2 years, with a mean
rate of contacts per full-time case manager per month of 48 (range
35–60). There was no variation in the proportion of non-medical contacts
when case-load sizes were over 1:20 but there was a convincing linear
relationship when sizes were between 1:10 and 1:20.
Case-load size between 1:10 and 1:20 does affect the practice of case
management. However, there is no support for a paradigm shift in practice
at a discrete level.
It has been suggested that people with psychopathic disorders lack
empathy because they have deficits in processing distress cues (e.g.
fearful facial expressions).
To investigate brain function when individuals with psychopathy and a
control group process facial emotion.
Using event-related functional magnetic resonance imaging we compared six
people scoring ⩾25 on the Hare Psychopathy Checklist–Revised and nine
non-psychopathic healthy volunteers during an implicit emotion processing
task using fearful, happy and neutral faces.
The psychopathy group showed significantly less activation than the
control group in fusiform and extrastriate cortices when processing both
facial emotions. However, emotion type affected response pattern. Both
groups increased fusiform and extrastriate cortex activation when
processing happy faces compared with neutral faces, but this increase was
significantly smaller in the psychopathy group. In contrast, when
processing fearful faces compared with neutral faces, the control group
showed increased activation but the psychopathy group decreased
activation in the fusiform gyrus.
People with psychopathy have biological differences from controls when
processing facial emotion, and the pattern of response differs according
to emotion type.
Little is known about the determinants of violence in women with psychosis.
To identify predictors of violence in a community sample of women with chronic psychosis.
The 2-year prevalence of physical assault was estimated for a sample of 304 women with psychosis. Baseline socio-demographic and clinical factors were used to identify predictors of assault.
The 2-year prevalence of assault in the sample was 17%. Assaultive behaviour was associated with previous violence (OR=5.87, 95% CI 2.42–14.25), non-violent convictions (OR=2.63, 95% CI 1.17–5.93), victimisation (OR=2.46, 95% CI 1.02–5.93), African–Caribbean ethnicity (OR=2.24, 95% CI 1.02–4.77), cluster B personality disorder (OR=2.66, 95% CI 1.11–6.38) and high levels of unmet need (OR=1.17, 95%C11.01–1.35). An interaction between African–Caribbean ethnicity and cluster B personality disorder was identified in relation to violent outcome. Violent women were found to be more costly to services.
Nearly a fifth of community-dwelling women with chronic psychosis committed assault over a period of 2 years. Six independent risk factors were found to predict violence.
Since de-institutionalisation, much has been written about the risk posed to the community by those with severe mental illness. However, violent victimisation of people with mental illnesses has received little attention.
To establish the 1-year prevalence of violent victimisation in community-dwelling patients with psychosis and to identify the socio-demographic and clinical correlates of violent victimisation.
A total of 691 subjects with established psychotic disorders were interviewed. The past-year prevalence of violent victimisation was estimated and compared with general population figures. Those who reported being violently victimised were compared with those who did not on a range of social and clinical characteristics.
Sixteen per cent of patients reported being violently victimised. Victims of violence were significantly more likely to report severe psychopathological symptoms, homelessness, substance misuse and previous violent behaviour and were more likely to have a comorbid personality disorder.
Those with psychosis are at considerable risk of violent victimisation in the community. Victimisation experience should be recorded in the standard psychiatric interview.
The impact of comorbid personality disorder on the occurrence of violence in psychosis has not been fully explored.
To examine the association between comorbid personality disorder and violence in community-dwelling patients with psychosis.
A total of 670 patients with established psychotic illness were screened for comorbid personality disorder. Physical assault was measured from multiple data sources over the subsequent 2 years. Logistic regression was used to assess whether the presence of comorbid personality disorder predicted violence in the sample.
A total of 186 patients (28%) were rated as having a comorbid personality disorder. Patients with comorbid personality disorder were significantly more likely to behave violently over the 2-year period of the trial (adjusted odds ratio = 1.71, 95% CI 1.05–2.79).
Comorbid personality disorder is independently associated with an increased risk of violent behaviour in psychosis.
Trials in community psychiatry must balance rigour with generalisability. The UK700 trial failed to find a significant effect on hospitalisation, but its sample population contained significant heterogeneity of exposure to case management in the two groups.
To test whether patients successfully exposed to a minimum of 12 months' intensive case management over the 2-year follow-up period achieved reduced hospitalisation.
Of 679 participants with hospitalisation data, 84 were identified as having < 12 months' exposure owing to prolonged hospitalisation, imprisonment or a combination of the two. These patients were excluded and outcomes tested for the remaining 595 patients.
Overall reduced case-load size did not reduce hospitalisation or treatment costs over 2 years despite elimination of outliers. Age, previous hospitalisation and source of recruitment to the study all correlated with outcome.
Case-load reduction is not in itself enough to reduce the need for hospital care in psychosis. Baseline patient characteristics (in particular length of previous hospitalisation and recruitment from in-patient care) have a significant influence and should be allowed for in power calculations. Identifying the optimal clinical profile for patients likely to benefit from intensive case management remains a pressing need for further studies.
The literature concerning psychiatrists' responses to patient suicide is sparse (Brown, 1987; Chemtob et al, 1988; Alexander et al, 2000) but even less attention has been given to the psychiatrist's role in the aftermath of such an event. Psychiatrists infrequently discuss their own experience of patient suicide with their colleagues, either at an individual level (Kaye & Soreff, 1991) or in group settings such as team meetings (Ruben, 1990). This is all the more remarkable when one acknowledges that the suicide of a patient is arguably the event that causes most concern for clinicians, irrespective of their experience or seniority (Kaye & Soreff, 1991).
The isolation experienced by many patients with severe psychotic disorders is generally assumed to be due to their social withdrawal. An alternative possibility is that relatives avoid frequent contact with patients because they find the situation distressing.
To examine the predictors of frequent patient-relative contact, in particular the role of relatives' experience.
UK700 trial data were used to determine baseline predictors of frequent contact and establish whether relatives' experience at baseline predicted continued frequent contact 2 years later.
Neither characteristics associated in the literature with relatives' ‘burden’ nor relatives' experience predicted patient-relative contact frequency. Instead, the predictors were mainly demographic.
Many relatives experience considerable distress, but the evidence does not suggest that they avoid frequent contact with the patient as a consequence.
Studies of intensive case management (ICM) for patients with psychotic illnesses have produced conflicting results in terms of outcome. Negative results have sometimes been attributed to a failure to deliver differing patterns of care.
To test whether the actual care delivered in a randomised clinical trial of ICM v. standard case management (the UK700 trial) differed significantly.
Data on 545 patients' care were collected over 2 years. All patient contacts and all other patient-centred interventions (e.g. telephone calls, carer contacts) of over 15 minutes were prospectively recorded. Rates and distributions of these interventions were compared.
Contact frequency was more than doubled in the ICM group. There were proportionately more failed contacts and carer contacts but there was no difference in the average length of individual contacts or the proportion of contacts in the patients' homes.
The failure to demonstrate outcome differences in the UK700 study is not due to a failure to vary the treatment process. UK standard care contains many of the characteristics of assertive outreach services and differences in outcome may require that greater attention be paid to delivering evidence-based interventions.
A case of self-inflicted eye injury is described in a setting of alcohol intoxication and severe personality disturbance. The case is believed to be the only one of its type described this century. The relevant classical and contemporary literature is reviewed and psychopathological explanations discussed. Possible indicators of impending self-violence are reviewed.