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Outcome measurement in forensic mental health services can support service improvement, research, and patient progress evaluation. This systematic review aims to identify instruments available for use as outcome measures in this field and assess the evidence for the most common instruments, specific to the forensic context, which cover multiple outcome domains.
Studies were identified by searching seven online databases. Additional searches were then performed for 10 selected instruments to identify additional information on their psychometric properties. Instrument manuals and gray literature was reviewed for information about instrument development and content validity. The quality of evidence for psychometric properties was summarized for each instrument based on the COnsensus-based Standards for health Measurement INstruments (COSMIN) approach.
A total of 435 different instruments or variants were identified. Psychometric information on the 10 selected instruments was extracted from 103 studies. All 10 instruments had a clinician reported component with only two having patient reported scales. Half of the instruments were primarily focused on risk. No instrument demonstrated adequate psychometric properties in all eight COSMIN categories assessed. Only one instrument, the Camberwell Assessment of Need: Forensic Version, had adequate evidence for its development and content validity. The most evidence was for construct validity, while none was identified for construct stability between groups.
Despite the large number of instruments potentially available, evidence for their use as outcome measures in forensic mental health services is limited. Future research and instrument development should involve patients and carers to ensure adequate content validity.
Violence perpetrated by psychiatric inpatients is associated with modifiable factors. Current structured approaches to assess inpatient violence risk lack predictive validity and linkage to interventions.
Adult psychiatric inpatients on forensic and general wards in three psychiatric hospitals were recruited and followed up prospectively for 6 months. Information on modifiable (dynamic) risk factors were collected every 1–4 weeks, and baseline background factors. Data were transferred to a web-based monitoring system (FOxWeb) to calculate a total dynamic risk score. Outcomes were extracted from an incident-reporting system recording aggression and interpersonal violence. The association between total dynamic score and violent incidents was assessed by multilevel logistic regression and compared with dynamic score excluded.
We recruited 89 patients and conducted 624 separate assessments (median 5/patient). Mean age was 39 (s.d. 12.5) years with 20% (n = 18) female. Common diagnoses were schizophrenia-spectrum disorders (70%, n = 62) and personality disorders (20%, n = 18). There were 93 violent incidents. Factors contributing to violence risk were a total dynamic score of ⩾1 (OR 3.39, 95% CI 1.25–9.20), 10-year increase in age (OR 0.67, 0.47–0.96), and female sex (OR 2.78, 1.04–7.40). Non-significant associations with schizophrenia-spectrum disorder were found (OR 0.50, 0.20–1.21). In a fixed-effect model using all covariates, AUC was 0.77 (0.72–0.82) and 0.75 (0.70–0.80) when the dynamic score was excluded.
In predicting violence risk in individuals with psychiatric disorders, modifiable factors added little incremental value beyond static ones in a psychiatric inpatient setting. Future work should make a clear distinction between risk factors that assist in prediction and those linked to needs.
Individuals diagnosed with psychiatric disorders who are prescribed antipsychotics have lower rates of violence and crime but the differential effects of specific antipsychotics are not known. We investigated associations between 10 specific antipsychotic medications and subsequent risks for a range of criminal outcomes.
We identified 74 925 individuals who were ever prescribed antipsychotics between 2006 and 2013 using nationwide Swedish registries. We tested for five specific first-generation antipsychotics (levomepromazine, perphenazine, haloperidol, flupentixol, and zuclopenthixol) and five second-generation antipsychotics (clozapine, olanzapine, quetiapine, risperidone, and aripiprazole). The outcomes included violent, drug-related, and any criminal arrests and convictions. We conducted within-individual analyses using fixed-effects Poisson regression models that compared rates of outcomes between periods when each individual was either on or off medication to account for time-stable unmeasured confounders. All models were adjusted for age and concurrent mood stabilizer medications.
The relative risks of all crime outcomes were substantially reduced [range of adjusted rate ratios (aRRs): 0.50–0.67] during periods when the patients were prescribed antipsychotics v. periods when they were not. We found that clozapine (aRRs: 0.28–0.44), olanzapine (aRRs: 0.46–0.72), and risperidone (aRRs: 0.53–0.64) were associated with lower arrest and conviction risks than other antipsychotics, including quetiapine (aRRs: 0.68–0.84) and haloperidol (aRRs: 0.67–0.77). Long-acting injectables as a combined medication class were associated with lower risks of the outcomes but only risperidone was associated with lower risks of all six outcomes (aRRs: 0.33–0.69).
There is heterogeneity in the associations between specific antipsychotics and subsequent arrests and convictions for any drug-related and violent crimes.
The coronavirus disease 2019 (COVID-19) pandemic is a major threat to the public. However, the comprehensive profile of suicidal ideation among the general population has not been systematically investigated in a large sample in the age of COVID-19.
A national online cross-sectional survey was conducted between February 28, 2020 and March 11, 2020 in a representative sample of Chinese adults aged 18 years and older. Suicidal ideation was assessed using item 9 of the Patient Health Questionnaire-9. The prevalence of suicidal ideation and its risk factors was evaluated.
A total of 56,679 participants (27,149 males and 29,530 females) were included. The overall prevalence of suicidal ideation was 16.4%, including 10.9% seldom, 4.1% often, and 1.4% always suicidal ideation. The prevalence of suicidal ideation was higher in males (19.1%) and individuals aged 18–24 years (24.7%) than in females (14.0%) and those aged 45 years and older (11.9%). Suicidal ideation was more prevalent in individuals with suspected or confirmed infection (63.0%), frontline workers (19.2%), and people with pre-existing mental disorders (41.6%). Experience of quarantine, unemployed, and increased psychological stress during the pandemic were associated with an increased risk of suicidal ideation and its severity. However, paying more attention to and gaining a better understanding of COVID-19-related knowledge, especially information about psychological interventions, could reduce the risk.
The estimated prevalence of suicidal ideation among the general population in China during COVID-19 was significant. The findings will be important for improving suicide prevention strategies during COVID-19.
Little is known about the trend and predictors of 21-year mortality and suicide patterns in persons with schizophrenia.
To explore the trend and predictors of 21-year mortality and suicide in persons with schizophrenia in rural China.
This longitudinal follow-up study included 510 persons with schizophrenia who were identified in a mental health survey of individuals (≥15 years old) in 1994 in six townships of Xinjin County, Chengdu, China, and followed up in three waves until 2015. Kaplan–Meier survival analysis and Cox hazard regressions were conducted.
Of the 510 participants, 196 died (38.4% mortality) between 1994 and 2015; 13.8% of the deaths (n = 27) were due to suicide. Life expectancy was lower for men than for women (50.6 v. 58.5 years). Males consistently showed higher rates of mortality and suicide than females. Older participants had higher mortality (hazard ratio HR = 1.03, 95% CI 1.01–1.05) but lower suicide rates (HR = 0.95, 95% CI 0.93–0.98) than their younger counterparts. Poor family attitudes were associated with all-cause mortality and death due to other causes; no previous hospital admission and a history of suicide attempts independently predicted death by suicide.
Our findings suggest there is a high mortality and suicide rate in persons with schizophrenia in rural China, with different predictive factors for mortality and suicide. It is important to develop culture-specific, demographically tailored and community-based mental healthcare and to strengthen family intervention to improve the long-term outcome of persons with schizophrenia.
Self-harm is common in prisoners. There is an association between self-harm in prisoners and subsequent suicide, both within prison and on release. The aim of this study is to develop and evaluate a prediction model to identify male prisoners at high risk of self-harm.
We developed an 11-item screening model, based on risk factors identified from the literature. This screen was administered to 542 prisoners within 7 days of arrival in two male prisons in England. Participants were followed up for 6 months to identify those who subsequently self-harmed in prison. Analysis was conducted using Cox proportional hazard regression. Discrimination and calibration were determined for the model. The model was subsequently optimized using multivariable analysis, weighting variables, and dropping poorly performing items.
Seventeen (3.1%) of the participants self-harmed during follow up (median 53 days). The strongest risk factors were previous self-harm in prison (adjusted hazard ratio [aHR] = 9.3 [95% CI: 3.3–16.6]) and current suicidal ideation (aHR = 7.6 [2.1–27.4]). As a continuous score, a one-point increase in the suicide screen was significantly associated with self-harm (HR = 1.4, 1.1–1.7). At the prespecified cut off score of 5, the screening model was associated with an area under the curve (AUC) of 0.66 (0.53–0.79), with poor calibration. The optimized model saw two items dropped from the original screening tool, weighting of risk factors based on a multivariable model, and an AUC of 0.84 (0.76–0.92).
Further work is necessary to clarify the association between risk factors and self-harm in prison. Despite good face validity, current screening tools for self-harm need validation in new prison samples.
Violent behaviour by forensic psychiatric inpatients is common. We aimed to systematically review the performance of structured risk assessment tools for violence in these settings.
The nine most commonly used violence risk assessment instruments used in psychiatric hospitals were examined. A systematic search of five databases (CINAHL, Embase, Global Health, PsycINFO and PubMed) was conducted to identify studies examining the predictive accuracy of these tools in forensic psychiatric inpatient settings. Risk assessment instruments were separated into those designed for imminent (within 24 hours) violence prediction and those designed for longer-term prediction. A range of accuracy measures and descriptive variables were extracted. A quality assessment was performed for each eligible study using the QUADAS-2. Summary performance measures (sensitivity, specificity, positive and negative predictive values, diagnostic odds ratio, and area under the curve value) and HSROC curves were produced. In addition, meta-regression analyses investigated study and sample effects on tool performance.
Fifty-two eligible publications were identified, of which 43 provided information on tool accuracy in the form of AUC statistics. These provided data on 78 individual samples, with information on 6,840 patients. Of these, 35 samples (3,306 patients from 19 publications) provided data on all performance measures. The median AUC value for the wider group of 78 samples was higher for imminent tools (AUC 0.83; IQR: 0.71–0.85) compared with longer-term tools (AUC 0.68; IQR: 0.62-0.75). Other performance measures indicated variable accuracy for imminent and longer-term tools. Meta-regression indicated that no study or sample-related characteristics were associated with between-study differences in AUCs.
The performance of current tools in predicting risk of violence beyond the first few days is variable, and the selection of which tool to use in clinical practice should consider accuracy estimates. For more imminent violence, however, there is evidence in support of brief scalable assessment tools.
Substance use disorder explains much of the excess risk of violent behaviour in psychotic disorders. However, it is unclear to what extent the pharmacological properties and subthreshold use of illicit substances are associated with violence.
Individuals with psychotic disorders were recruited for two nationwide projects: GROUP (N = 871) in the Netherlands and NEDEN (N = 921) in the United Kingdom. Substance use and violent behaviour were assessed with standardized instruments and multiple sources of information. First, we used logistic regression models to estimate the associations of daily and nondaily use with violence for cannabis, stimulants, depressants and hallucinogens in the GROUP and NEDEN samples separately. Adjustments were made for age, sex and educational level. We then combined the results in random-effects meta-analyses.
Daily use, compared with nondaily or no use, and nondaily use, compared with no use, increased the pooled odds of violence in people with psychotic disorders for all substance categories. The increases were significant for daily use of cannabis [pooled odds ratio (pOR) 1.6, 95% confidence interval (CI) 1.2–2.0), stimulants (pOR 2.8, 95% CI 1.7–4.5) and depressants (pOR 2.2, 95% CI 1.1–4.5), and nondaily use of stimulants (pOR 1.6, 95% CI 1.2–2.0) and hallucinogens (pOR 1.5, 95% CI 1.1–2.1). Daily use of hallucinogens, which could only be analysed in the NEDEN sample, significantly increased the risk of violence (adjusted odds ratio 3.3, 95% CI 1.2–9.3).
Strategies to prevent violent behaviour in psychotic disorders should target any substance use.
We aimed to systematically review risk factors for criminal recidivism in individuals given community sentences.
We searched seven bibliographic databases and additionally conducted targeted searches for studies that investigated risk factors for any repeat offending in individuals who had received community (non-custodial) sentences. We included investigations that reported data on at least one risk factor and allowed calculations of odds ratios (ORs). If a similar risk factor was reported in three or more primary studies, they were grouped into domains, and pooled ORs were calculated.
We identified 15 studies from 5 countries, which reported data on 14 independent samples and 246,608 individuals. We found that several dynamic (modifiable) risk factors were associated with criminal recidivism in community-sentenced populations, including mental health needs (OR = 1.4, 95% confidence interval (CI): 1.2–1.6), substance misuse (OR = 2.3, 95% CI: 1.1–4.9), association with antisocial peers (OR = 2.2, 95% CI: 1.3–3.7), employment problems (OR = 1.8, 95% CI: 1.3–2.5), marital status (OR = 1.6, 95%: 1.4–1.8), and low income (OR = 2.0, 95% CI: 1.1–3.4). The strength of these associations was comparable to that of static (non-modifiable) risk factors, such as age, gender, and criminal history.
Assessing dynamic (modifiable) risk factors should be considered in all individuals given community sentences. The further integration of mental health, substance misuse, and criminal justice services may reduce reoffending risk in community-sentenced populations.
Interpersonal violence is a leading cause of morbidity and mortality. The strength and population effect of modifiable risk factors for interpersonal violence, and the quality of the research evidence is not known.
We aimed to examine the strength and population effect of modifiable risk factors for interpersonal violence, and the quality and reproducibility of the research evidence.
We conducted an umbrella review of systematic reviews and meta-analyses of risk factors for interpersonal violence. A systematic search was conducted to identify systematic reviews and meta-analyses in general population samples. Effect sizes were extracted, converted into odds ratios and synthesised, and population attributable risk fractions (PAF) were calculated. Quality analyses were performed, including of small study effects, adjustment for confounders and heterogeneity. Secondary analyses for aggression, intimate partner violence and homicide were conducted, and systematic reviews (without meta-analyses) were summarised.
We identified 22 meta-analyses reporting on risk factors for interpersonal violence. Neuropsychiatric disorders were among the strongest in relative and absolute terms. The neuropsychiatric risk factor that had the largest effect at a population level were substance use disorders, with a PAF of 14.8% (95% CI 9.0–21.6%), and the most important historical factor was witnessing or being a victim of violence in childhood (PAF = 12.2%, 95% CI 6.5–17.4%). There was evidence of small study effects and large heterogeneity.
National strategies for the prevention of interpersonal violence may need to review policies concerning the identification and treatment of modifiable risk factors.
Declarations of interest
J.R.G. is an NIHR Senior Investigator. The views expressed within this article are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.
Despite evidence of links between depression and violent outcomes, potential moderators of this association remain unknown. The current study tested whether a biological marker, cortisol, moderated this association in a longitudinal sample of adolescents.
Participants were 358 Dutch adolescents (205 boys) with a mean age of 15 years at the first measurement. Depressive symptoms, the cortisol awakening response (CAR) and violent outcomes were measured annually across 3 years. The CAR was assessed by two measures: waking cortisol activity (CAR area under the curve ground) and waking cortisol reactivity (CAR area under the curve increase). Within-individual regression models were adopted to test the interaction effects between depressive symptoms and CAR on violent outcomes, which accounted for all time-invariant factors such as genetic factors and early environments. We additionally adjusted for time-varying factors including alcohol drinking, substance use and stressful life events.
In this community sample, 24% of adolescents perpetrated violent behaviours over 3 years. We found that CAR moderated the effects of depressive symptoms on adolescent violent outcomes (βs ranged from −0.12 to −0.28). In particular, when the CAR was low, depressive symptoms were positively associated with violent outcomes in within-individual models, whereas the associations were reversed when the CAR was high.
Our findings suggest that the CAR should be investigated further as a potential biological marker for violence in adolescents with high levels of depressive symptoms.
Secure hospitals are a high-cost, low-volume service consuming around a
fifth of the overall mental health budget in England and Wales.
A systematic review and meta-analysis of adverse outcomes after discharge
along with a comparison with rates in other clinical and forensic groups
in order to inform public health and policy.
We searched for primary studies that followed patients discharged from a
secure hospital, and reported mortality, readmissions or reconvictions.
We determined crude rates for all adverse outcomes.
In total, 35 studies from 10 countries were included, involving 12 056
patients out of which 53% were violent offenders. The crude death rate
for all-cause mortality was 1538 per 100 000 person-years (95% CI
1175–1901). For suicide, the crude death rate was 325 per 100 000
person-years (95% CI 235– 415). The readmission rate was 7208 per 100 000
person-years (95% CI 5916–8500). Crude reoffending rates were 4484 per
100 000 person-years (95% CI 3679–5287), with lower rates in more recent
There is some evidence that patients discharged from forensic psychiatric
services have lower offending outcomes than many comparative groups.
Services could consider improving interventions aimed at reducing
premature mortality, particularly suicide, in discharged patients.
Violence risk assessment in schizophrenia relies heavily on criminal history factors.
To investigate which criminal history factors are most strongly associated with violent crime in schizophrenia.
A total of 13 806 individuals (8891 men and 4915 women) with two or more hospital admissions for schizophrenia were followed up for violent convictions. Multivariate hazard ratios for 15 criminal history factors included in different risk assessment tools were calculated. The incremental predictive validity of these factors was estimated using tests of discrimination, calibration and reclassification.
Over a mean follow-up of 12.0 years, 17.3% of men (n=1535) and 5.7% of women (n=281) were convicted of a violent offence. Criminal history factors most strongly associated with subsequent violence for both men and women were a previous conviction for a violent offence; for assault, illegal threats and/or intimidation; and imprisonment. However, only a previous conviction for a violent offence was associated with incremental predictive validity in both genders following adjustment for young age and comorbid substance use disorder.
Clinical and actuarial approaches to assess violence risk can be improved if included risk factors are tested using multiple measures of performance.
Rates of violence in persons identified as high risk by structured risk
assessment instruments (SRAIs) are uncertain and frequently unreported by
To analyse the variation in rates of violence in individuals identified
as high risk by SRAIs.
A systematic search of databases (1995–2011) was conducted for studies on
nine widely used assessment tools. Where violence rates in high-risk
groups were not published, these were requested from study authors. Rate
information was extracted, and binomial logistic regression was used to
Information was collected on 13 045 participants in 57 samples from 47
independent studies. Annualised rates of violence in individuals
classified as high risk varied both across and within instruments. Rates
were elevated when population rates of violence were higher, when a
structured professional judgement instrument was used and when there was
a lower proportion of men in a study.
After controlling for time at risk, the rate of violence in individuals
classified as high risk by SRAIs shows substantial variation. In the
absence of information on local base rates, assigning predetermined
probabilities to future violence risk on the basis of a structured risk
assessment is not supported by the current evidence base. This
underscores the need for caution when such risk estimates are used to
influence decisions related to individual liberty and public safety.
Recruitment of adequate numbers of doctors to psychiatry is difficult.
To report on career choice for psychiatry, comparing intending psychiatrists with doctors who chose other clinical careers.
Questionnaire studies of all newly qualified doctors from all UK medical schools in 12 qualification years between 1974 and 2009 (33 974 respondent doctors).
One, three and five years after graduation, 4–5% of doctors specified psychiatry as their first choice of future career. This was largely unchanged across the 35 years. Comparing intending psychiatrists with doctors who chose other careers, factors with a greater influence on psychiatrists' choice included their experience of the subject at medical school, self-appraisal of their own skills, and inclinations before medical school. In a substudy of doctors who initially considered but then did not pursue specialty choices, 72% of those who did not pursue psychiatry gave ‘job content’ as their reason compared with 33% of doctors who considered but did not pursue other specialties. Historically, more women than men have chosen psychiatry, but the gap has closed over the past decade.
Junior doctors' views about psychiatry as a possible career range from high levels of enthusiasm to antipathy, and are more polarised than views about other specialties. Shortening of working hours and improvements to working practices in other hospital-based specialties in the UK may have reduced the relative attractiveness of psychiatry to women doctors. The extent to which views of newly qualified doctors about psychiatry can be modified by medical school education, and by greater exposure to psychiatry during student and early postgraduate years, needs investigation.
High levels of psychiatric morbidity in prisoners have been documented in
many countries, but it is not known whether rates of mental illness have
been increasing over time or whether the prevalence differs between
low–middle-income countries compared with high-income ones.
To systematically review prevalence studies for psychotic illness and
major depression in prisoners, provide summary estimates and investigate
sources of heterogeneity between studies using meta-regression.
Studies from 1966 to 2010 were identified using ten bibliographic indexes
and reference lists. Inclusion criteria were unselected prison samples
and that clinical examination or semi-structured instruments were used to
make DSM or ICD diagnoses of the relevant disorders.
We identified 109 samples including 33 588 prisoners in 24 countries.
Data were meta-analysed using random-effects models, and we found a
pooled prevalence of psychosis of 3.6% (95% CI 3.1–4.2) in male prisoners
and 3.9% (95% CI 2.7–5.0) in female prisoners. There were high levels of
heterogeneity, some of which was explained by studies in
low–middle-income countries reporting higher prevalences of psychosis
(5.5%, 95% CI 4.2–6.8; P=0.035 on meta-regression). The
pooled prevalence of major depression was 10.2% (95% CI 8.8–11.7) in male
prisoners and 14.1% (95% CI 10.2–18.1) in female prisoners. The
prevalence of these disorders did not appear to be increasing over time,
apart from depression in the USA (P=0.008).
High levels of psychiatric morbidity are consistently reported in
prisoners from many countries over four decades. Further research is
needed to confirm whether higher rates of mental illness are found in
low- and middle-income nations, and examine trends over time within
nations with large prison populations.
Although male prisoners are five times more likely to die by suicide than men of a similar age in the general population, the contribution of psychiatric disorders is not known.
To investigate the association of psychiatric disorders with near-lethal suicide attempts in male prisoners.
A matched case–control study of 60 male prisoners who made near-lethal suicide attempts (cases) and 60 prisoners who had never carried out near-lethal suicide attempts in prison (controls) was conducted. Psychiatric disorders were identified with the Mini International Neuropsychiatric Interview (MINI), and information on sociodemographic characteristics and criminal history was gathered using a semi-structured interview.
Psychiatric disorders were present in all cases and 62% of controls. Most current psychiatric disorders were associated with near-lethal suicide attempts, including major depression (odds ratio (OR) = 42.0, 95% CI 5.8–305), psychosis (OR = 15.0, 95% CI 2.0–113), anxiety disorders (OR = 6.0, 95% CI 2.3–15.5) and drug misuse (OR = 2.9, 95% CI 1.3–6.4). Lifetime psychiatric disorders associated with near-lethal attempts included recurrent depression and psychoses. Although cases were more likely than controls to meet criteria for antisocial personality disorder, the difference was not statistically significant. Comorbidity was also significantly more common among cases than controls for both current and lifetime disorders.
In male prisoners, psychiatric disorders, especially depression, psychosis, anxiety and drug misuse, are associated with near-lethal suicide attempts, and hence probably with suicide.