Alberta not criminally responsible project: Rates of persons found NCRMD and absolute discharges in Alberta following the Not Criminally Responsible Reform Act

In 2014, then-Canadian Prime Minister Stephen Harper passed the Not Criminally Responsible Reform Act into law, which gave Canadian courts and Review Boards new powers to protect the public from particularly dangerous mentally ill offenders. The most controversial change to the law included the designation of the High-Risk Accused. Once designated by the courts as a High-Risk Accused, that individual is barred from leaving a forensic hospital except for urgent medical reasons. In this article, the authors assess the impact of the Not Criminally Responsible Reform Act on the forensic mental health system in Alberta, Canada. The findings indicate that the legislation did not lead to any meaningful changes in the Alberta forensic mental health system in terms of absolute discharges and incoming persons found not criminally responsible.

Access to non-violent pornography in a secure forensic hospital

Purpose The purpose of this paper is to explore non-violent pornography within secure hospital settings. Design/methodology/approach It includes a systematic review (n = 40 papers), followed by a qualitative study comprising semi-structured interviews (n = 24, 6 patients and 18 staff) and staff focus groups (n = 22 staff). Findings The systematic review identified six themes, as follows: pornography is inconsistently defined, pornography exposure can increase general aggression, pornography exposure may increase the risk for sexual aggression, pornography exposure can increase aggression supportive beliefs, pornography exposure impacts negatively on those with a violent predisposition and pornography is educational for men not identifying as heterosexual. The semi-structured interviews and focus groups revealed four themes as follows: staff members hold diverse beliefs about pornographic material, pornography is difficult to obtain and use for patients who do not identify as heterosexual, pornography is used for specific functions, and frequent exposure to pornography can have negative effects for staff members. Practical implications Trying to obtain consensus on the impacts of pornography on forensic patients is not possible; material access decisions should be on a case-by-case basis. Policy decisions should be based on fully represented views, including the LGBTI community. The impacts on staff of their occupational exposure to such material should be recognised and support provided. Clinical decision-making in this area should consider not only if access should be allowed but also how it can be managed safely, if at all. This includes for all those who could be exposed to such material, inadvertently or otherwise. Originality/value It addresses the under-researched area of patient access to pornography, capturing a poorly considered sample, namely, high secure psychiatric.

Augmentation of Antipsychotic Medications with Low-Dose Clozapine in Treatment-Resistant Schizophrenia—Case Reports and Discussion

Treatment resistance in schizophrenia is often encountered in clinical practice, with clozapine usually recommended as the appropriate therapy. However, where clozapine proves ineffective or cannot be tolerated due to side effects, treatment options are limited. In patients within forensic mental health services, residual symptomatology often presents a barrier to discharge and can have lasting effects on prospects for rehabilitation as well as risk to self and others. This paper presents a review of the relevant literature and three cases of a novel approach, utilising clozapine in doses usually considered subtherapeutic, in combination with the primary antipsychotic treatment. In all three patients, it improved clinical efficacy as well as tolerability, resulting in improvement that allowed discharge from the forensic hospital.

Clozapine re-challenge and initiation following neutropenia: a review and case series of 14 patients in a high-secure forensic hospital

Objective: Clozapine remains the most effective intervention for treatment resistant schizophrenia; however, its use is prohibited following neutropenias. We review neutrophil biology as applied to clozapine and describe the strategies to initiate clozapine following neutropenia used in a case series of 14 consecutive patients rechallenged in a United Kingdom (UK) high-secure psychiatric hospital. We examine outcomes including the use of seclusion and transfer. Methods: A case series of 14 male patients with treatment resistant schizophrenia treated with clozapine despite previous episodes of neutropenia between 2006 and 2015 is presented. Data were collected during 2015 and 2019. Using this routinely collected clinical data, we describe the patient characteristics, causes of neutropenia, the strategies used for rechallenging with clozapine and clinical outcomes. Results: Previous neutropenias were the result of benign ethnic neutropenia, clozapine, other medications and autoimmune-related. Our risk mitigation strategies included: granulocyte-colony stimulating factor (G-CSF), lithium and watch-and-wait. There were no serious adverse events; at follow up half of the patient’s had improved sufficiently to transfer them to conditions of lesser security. There were dramatic reductions in the use of seclusion. Conclusion: Even in this extreme group, clozapine can be safely and effectively re/initiated following neutropenias, resulting in marked benefits for patients. This requires careful planning based on an understanding of neutrophil biology and the aetiology of the specific episode of neutropenia.

Admissions to the Western Australian state forensic hospital from court on hospital orders over a 10-year period from 2007 to 2016

Objective: To investigate trends in admissions to the state forensic hospital (Western Australia (WA)) from court on hospital orders from 2007 to 2016. Method: A retrospective survey was undertaken. Demographic, clinical and legal data were obtained from hospital records. Hospital orders referred on less serious charges or without a primary diagnosis of major mental illness were identified as ‘non-forensic’. Results: There were 890 hospital orders representing 40% of total admissions. Eighty-one per cent were male and 50% had a diagnosis of schizophrenia; 22% were Indigenous; 421 (47%) were admitted on less serious (non-Schedule 1) charges; 199 (22%) did not have a primary diagnosis of a major mental illness recorded on the discharge summary; 82 (9%) had neither major mental illness nor serious charges. Overall, 539 hospital orders (60%) were identified as non-forensic; 243 (45%) of these were made with no input from the Court Liaison Service (CLS). Conclusions: Hospital orders make up a significant proportion of admissions to the forensic unit in WA. Many do not require secure forensic care. Developing alternative diversion pathways is essential.

Outcome measures of risk and recovery in Broadmoor High Secure Forensic Hospital: stratification of care pathways and moves to medium secure hospitals

Background Placements within high secure forensic hospitals consist of wards providing various different levels of relational security. They should form a coherent pathway through secure care, based on individual patient risks and needs. Moves to less secure wards within high secure forensic hospitals and moves on to lower secure hospital settings have rarely been systematically studied. Aims The aim of this study was to ascertain if placements within Broadmoor High Secure Hospital and moves from Broadmoor to medium secure hospitals corresponded to measures of violence risk, programme completion and recovery. Method A 13-month prospective cohort study was completed. Patients (n = 142) were rated at baseline for violence risk (Historical, Clinical and Risk – 20), therapeutic programme completion and recovery (DUNDRUM tool) and overall functioning (Global Assessment of Functioning). Placements on the care pathway and moves on to medium secure hospitals were observed. Results Placements on the care pathway within the high secure hospital were associated with dynamic violence risk (F = 16.324, P<0.001), therapeutic programme completion (F = 4.167, P = 0.003), recovery (F = 2.440, P = 0.050) with better scores on these measures being found in the rehabilitation wards and the poorest scores on the highest levels of dependency. Moves to medium secure hospitals were associated with better scores on dynamic risk of violence (F = 33.199, P<0.001), therapeutic programme completion (F = 9.237 P<0.001), recovery (F = 6.863, P = 0.001). Conclusions Placements within Broadmoor Hospital formed a coherent pathway through high secure care. Moves to less secure places were influenced by more than reduction in violence risk. Therapeutic programme completion and recovery in a broad sense were also important.

A commentary on 'The Silent Patient' by Alex Michaelides

This commentary focuses on Alex Michaelides’ recent bestselling book 'The Silent Patient'. I use the book’s theme of a woman’s murder of her husband and her silence over six years of psychotherapy, to explore the resisting patient in a forensic hospital. I will focus on questions including the function of silence on the psychotherapy of violent patients; problems confronting forensic psychotherapists regarding the diagnosis and treatment of violent patients; issues of revenge secondary to family traumas and childhood trauma; relational issues on the treatment of violent patients where murder has been committed; and issues related to silence, lying, deceit in the consultation room and the meaning of such communications in the course of forensic psychotherapy.

Breaking down long-term chronic aggression within a forensic hospital system

Objective.Historically, patients with multiple acts of aggression, or chronic aggressors, have been studied as one large group. It was our objective to subdivide this group into those patients who engage in physical aggression consistently over multiple years and see if common characteristics of chronic aggressors could classify patients into an aggressive or nonaggressive group.Method.Within a forensic hospital system, patients who had committed 5 acts of physical aggression, per year, for 3 years (2010 and 2015) were reviewed. Data was collected on clinical and demographic characteristics that have shown to be associated with chronically aggressive patients and compared to nonaggressive matched controls. Data collection and analysis were completed to determine if the variables could classify patients into an aggressive or nonaggressive group.Results.Analysis showed that 2 variables, the presence of a cognitive disorder and a history of suicidal behaviors were significant in the univariate and multivariate analyses. The 2 variables were able to correctly classify 76.7% of the cases.Conclusion.A cognitive disorder, a history of suicidal behavior, and increased age were factors associated with this subgroup of aggressive patients. Clinicians may want to explore treatment programs aimed at these clinical factors including cognitive rehabilitation and social cognition treatments, which have been shown to reduce aggression in cognitively impaired populations.