Historical, clinical and situational risk factors for post-discharge recidivism in forensic psychiatric patients - A Swedish registry study

Previous research has shown that forensic psychiatric treatment reduces reoffending, rehospitalization and premature mortality. Treatment outcome varies with diagnosis, but little is known about the influence of sex, psychosocial adjustment and aftercare. To assess these variables, we interviewed male and female patients discharged from three psychiatric security hospitals in Germany in the years 2010-2017. Participants were interviewed at discharge (n = 609) and 1 year later (n = 366) about reoffending, readmissions, substance use and psychosocial adjustment. Among patients with substance use disorder (SUD), 14% reoffended, 20% were re-hospitalized and 60% maintained abstinence. Among patients with severe mental disorder, 5% reoffended and 13% were re-hospitalized. Significant sex differences were found in offenders with SUD. The results suggest that sociodemographic and disorder-related risk factors are associated with treatment success and that female patients with SUD might need a specific treatment approach. Sex-specific aspects, diagnosis and psychosocial adjustment should be considered in forensic psychiatric treatment and risk assessment.

https://www.onlinelibrary.wiley.com/doi/pdf/10.1002/bsl.2483

Comparison of outcome in men and women after treatment in psychiatric security hospitals in Germany.

This study investigated which risk and protective factors, based on the 14 clinical indicators of the Historical-Clinical-Future Revised, significantly predicted violent recidivism in a sample of 315 male forensic psychiatric patients. Additionally, it was investigated whether these associations were moderated by intellectual ability. Regarding risk factors, a stronger influence of risky network members, and higher levels of hostility, impulsivity, and addiction significantly predicted violent recidivism. Likewise, regarding protective factors, poorer social and labor skills, and a lower degree of patient's acceptance of crime responsibility were significant predictors of violent recidivism. Contrary to our expectations, better coping skills and more insight into risky behaviors that can lead to relapse also contributed significantly to an increased likelihood of violent recidivism. Intellectual ability had no significant moderating effect on the associations between the factors and violent recidivism. The results offer an insight into which factors need to be prioritized during treatment. 

The Role of Dynamic Risk and Protective Factors in Predicting Violent Recidivism: Intellectual Ability as a Possible Moderator?

Violence risk assessment is a routine part of clinical services in mental health, and in particular secure psychiatric hospitals. The use of prediction models and risk tools can assist clinical decision-making on risk management, including decisions about further assessments, referral, hospitalization and treatment. In recent years, scalable evidence-based tools, such as Forensic Psychiatry and Violent Oxford (FoVOx), have been developed and validated for patients with mental illness. However, their acceptability and utility in clinical settings is not known. Therefore, we conducted a clinical impact study in multiple institutions that provided specialist mental health service. We followed a two-step mixed-methods design. In phase one, we examined baseline risk factors on 330 psychiatric patients from seven forensic psychiatric institutes in China. In phase two, we conducted semi-structured interviews with 11 clinicians regarding violence risk assessment from ten mental health centres. We compared the FoVOx score on each admission (n = 110) to unstructured clinical risk assessment and used a thematic analysis to assess clinician views on the accuracy and utility of this tool. The median estimated probability of violent reoffending (FoVOx score) within 1 year was 7% (range 1–40%). There was fair agreement (72/99, 73% agreement) on the risk categories between FoVOx and clinicians’ assessment on risk categories, and moderate agreement (10/12, 83% agreement) when examining low and high risk categories. In a majority of cases (56/101, 55%), clinicians thought the FoVOx score was an accurate representation of the violent risk of an individual patient. Clinicians suggested some additional clinical, social and criminal risk factors should be considered during any comprehensive assessment. In addition, FoVOx was considered to be helpful in assisting clinical decision-making and individual risk assessment. Ten out of 11 clinicians reported that FoVOx was easy to use, eight out of 11 was practical, and all clinicians would consider using it in the future. Clinicians found that violence risk assessment could be improved by using a simple, scalable tool, and that FoVOx was feasible and practical to use.

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Assessment of violence risk in 440 psychiatric patients in China: examining the feasibility and acceptability of a novel and scalable approach (FoVOx).

Background The duration of forensic psychiatric care is in Sweden not determined at the time of sentencing; instead, offenders are regularly evaluated, often with regard to risk of criminal recidivism. The length and justifiability of such a sanction have been greatly debated; however, previous estimates of treatment duration based on datasets delimited to discharged patients—have provided an uncertain groundwork for these deliberations. The aim of this study was to use a more suitable approach to calculate average duration of forensic psychiatric care and to examine the relationship between length of treatment and subsequent recidivism after discharge. Methods This retrospective cohort study focused on offenders sentenced to forensic psychiatric care in Sweden between 2009 and 2019 and registered in the Swedish National Forensic Psychiatric Register (n = 2064), with a follow-up period until May 2020. We used Kaplan–Meier estimator to calculate and visualize treatment duration including analyses comparing levels of relevant variables, and then evaluated criminal recidivism in patients discharged from treatment between 2009 and 2019 (n = 640), after stratification for the same variables and dichotomization by treatment duration. Results The median duration of forensic psychiatric care was estimated to 89.7 months (95% CI 83.2–95.8). Treatment was longer in offenders who committed violent crimes, suffered from psychosis, or had a history of substance use disorder, and in offenders whose sentences included special court supervision. The cumulative incidence of recidivism in patients discharged from treatment was estimated to 13.5% at 12 months (95% CI 10.6–16.2) and 19.5% at 24 months (95% CI 16.0–22.8). Corresponding cumulative incidence of violent crime post discharge was 6.3% at 12 months (95% CI 4.3–8.3) and 9.9% at 24 months (95% CI 7.3–12.4). Among other findings, in patients without a history of substance use disorder and patients whose sentences did not include special court supervision, recidivism was significantly higher in those with a shorter treatment duration. Conclusion Using the entirety of a suitable, contemporary, prospectively enrolled cohort of mentally ill offenders, we were able to estimate—with greater accuracy than previous studies—the average duration of Swedish forensic psychiatric care and rate of subsequent criminal recidivism.

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Duration of forensic psychiatric care and subsequent criminal recidivism in individuals sentenced in Sweden between 2009 and 2019

This study examined associations between criminal recidivism after discharge from forensic treatment and variables related to either the time before the current forensic treatment, or the current forensic treatment, or the follow-up after discharge. Participants were treated in 12 forensic clinics according to section 63 of the German penal code. A patient was classified as a criminal recidivist when the patient or the aftercare reported that the patient was delinquent at follow-up. Patients without criminal recidivism were patients for which both perspectives (patient and aftercare) reported no delinquency at follow-up. Mann-Whitney U-tests and Fisher's exact tests were performed. Data to classify patients were available for N = 249 patients. Fifteen patients (6%) were classified as criminal recidivists. The follow-up was M = 12.58 (SD = 1.84) months, and the criminal acts occurred M = 6.00 (SD = 5.55) months after discharge. Differences between patients with and without criminal recidivism were found in pretreatment (young age at first crime, early onset of mental disorder, previous forensic treatments), treatment-related (disorder due to psychoactive substance use, gradual release abuses, outbreaks, assaults against staff, criminal act during treatment, type of discharge, outcome ratings), as well as follow-up variables (no specified housing situation, not being abstinent from psychoactive substances, inpatient readmission, course of outpatient treatment, course of mental disorder) (all p < 0.05). To conclude, it is important to consider variables related to the time before the current treatment, treatment-related variables, and variables related to the follow-up to identify the patients at risk of criminal recidivism after discharge from forensic treatment.

Wolfgang Mache

Papers

Criminal Recidivism After Forensic Psychiatric Treatment. A Multicenter Study on the Role of Pretreatment, Treatment-Related, and Follow-Up Variables