International Journal of Law and Psychiatry
Predictors of length of stay in forensic psychiatry: The influence of perceived risk of violence
Introduction
Approximately 350 people are court ordered to compulsory forensic psychiatric treatment in Sweden each year, a number that has been fairly stable since the late 1970s (Brottsförebyggande rådet, 2012). However, scientific knowledge of basic treatment conditions and care processes, such as length of stay and the prevalence of adverse events in forensic mental health services, is still scarce. In this article we aim to change this situation by presenting data about the treatment process for a Swedish population-based cohort of forensic psychiatric patients.
Unlike most countries, Sweden sentences mentally disordered offenders to forensic psychiatric care if they suffer from a “severe mental disorder,” a medico-legal term most often corresponding to a psychotic or severe mood disorder (Munthe, Radovic, & Anckarsäter, 2010). Patients who are subjected to a forensic psychiatric investigation are also assessed for their risk for recidivism into severe criminality due to their mental disorder; on average 80% are considered to be high-risk patients, far in excess of such rates in other countries (e.g., Crocker and Côte, 2009, Ferguson et al., 2009, Segal et al., 2010). These patients are placed under “special court supervision” (SCS) (Proposition, 1990/91:58), which means that they cannot be discharged without court approval. Thus, forensic psychiatry has the contradictory assignment to both treat the patient's psychiatric disorder and protect society (and the patient) from undesired behaviours, often through detention (SOU, 2006:91).
In Sweden the mean length of stay for male patients sentenced to forensic psychiatric treatment with SCS has been estimated at 5 years 9 months, while for those without SCS it was only 1 year 9 months (Socialstyrelsen, 2008). In the same report, patients with a diagnosis of schizophrenia or delusional disorder seemed to have longer hospital stays than those with affective disorders. Differences between the mental health care needs and the safety of the clinical care provided to patients with and without SCS have, however, not been studied.
International comparisons of length of stay in forensic psychiatry are hampered by differences in legislation and health care settings. In addition, different studies often report different measures of length of stay, using either means or medians (e.g., Coid, Kahtan, Gault, Cook, & Jarman, 2001 versus Simpson, Jones, Evans, & McKenna, 2006), which makes them hard to compare. It is also well known that psychiatric care settings tend to have a number of outliers in patients with extremely long hospital stays, which have large effects on reported means.
The main source of information about length of stay and the rate of adverse events (e.g., absconding [leaving without permission], violence, threats, and substance abuse) in Sweden is the cross-sectional inventory reports published by government agencies. These data collections invariably include data from a concentration of problem-prone, long-term patients, which could lead to flawed conclusions. For example, the rate of criminal recidivism during forensic psychiatric treatment in Sweden was estimated at 28% in one such report (Socialstyrelsen, 2002), a figure considerably higher than that found in a study by Nilsson, Wallinius, Gustavson, Anckarsäter, and Kerekes (2011), in which only 4% relapsed during ongoing forensic psychiatric treatment.
Among the adverse events that have the most negative effects, aggressive behaviour holds a conspicuous position, potentially causing severe physical or psychological injury to fellow patients, staff, or others, and often resulting in seclusion or transfer to a higher security ward or another hospital (Blow et al., 1999, Delaney et al., 2001). In a large literature review, Bowers et al. (2011) showed that forensic psychiatric services report a higher prevalence of violent patients and higher numbers of violent events per patient sample and per admission than acute settings and psychiatric hospitals, both within and across different countries (although, due to lack of consistency in reporting, it was difficult to compare these findings across separate studies). Few studies report on aggressive behaviours as adverse events per patient day, which would be an adequate measure since forensic psychiatry has very long hospital stays. The literature is also inconclusive as to which patients engage in aggressive events. Some studies suggest that it is a widespread phenomenon (e.g. Hodgins, Alderton, Cree, Aboud, & Mak, 2007), others report that only a small number of patients are involved in the majority of these situations (Daffern et al., 2005, Kraus and Sheitman, 2004). In a study of patients in a medium security unit (Gudjonsson, Rabe-Hesketh, & Wilson, 2000) the victims of aggressive behaviours were found primarily to be nursing staff, followed by fellow patients.
Absconding among psychiatric patients is another significant problem associated with both negative effects for the treatment process and potential harm to patients and the general public; the link between absconding and serious harm of self and others is especially strongly supported in the research literature (Muir-Cochrane & Mosel, 2008). In general psychiatry, the mean rate of absconding has been estimated at 12.6 per 100 patients, with a rather large variation ranging from 2 to 44 (Bowers, Jarrett, & Clark, 1998). In a study of absconding incidents at a UK psychiatric hospital, Dickens and Campbell (2001) reported that the minority (34%) of the patients who absconded accounted for almost two thirds of all incidents, with serious adverse outcomes in 16% of all incidents.
Several studies have identified substance abuse as a mediating factor that increases the propensity for violent reactions among people with mental illness (e.g., Elbogen and Johnson, 2009, Fazel et al., 2009), and as a predictor for aggressive behaviours among psychiatric inpatients (Serper et al., 2005). Substance abuse in combination with medication noncompliance among severely mentally ill individuals has emerged as an especially significant predictor of violent reactions (Swartz et al., 1998). Despite the strong association between substance abuse and violence in patients with major mental disorders, the consequences of relapses into drug abuse during ongoing treatment have rarely been subjected to any empirical studies, and have only occasionally been discussed in papers focusing on the treatment of this “triply troubled” patient group (e.g. Lindqvist, 2007).
The main objective of the present study is to describe the basic conditions of forensic psychiatric treatment in a population-based, epidemiologically representative, total cohort in Sweden over a specified period and to compare conditions for so called high-risk offenders with those for low-risk offenders. To the best of our knowledge, this is the first such endeavour also studying how the occurrence of adverse events affects the length of stay in compulsory forensic psychiatric treatment.
The specific questions were:
- 1.
How long are patients, subjected to involuntary forensic psychiatric treatment, hospitalized, and are there any differences in length of treatment between patients with and without a SCS?
- 2.
What is the prevalence of threats, violence, substance abuse, and absconding among these patients and are there significant differences between the groups in the frequency of these events?
- 3.
Which patient characteristics and treatment-related events predict patients' length of stay?
Section snippets
Participants
We conducted a retrospective file and register study of a population-based total cohort of patients sentenced to forensic psychiatric treatment in the University Hospital of Malmoe's catchment area between 1999 and 2005. The catchment area, which includes the districts of Malmoe, Svedala, Trelleborg, and Vellinge, is demographically representative of Sweden (containing urban, small town, and countryside areas). The total number of inhabitants in the area was around 361,000 at the end of 2005 (
Demographic characteristics
The study group characteristics are shown in Table 1. The most common crime classifications were assault (46 cases, 37%) and threats (42 cases, 34%). Of all violent convictions there were 5 murders, 4 attempted murders, 12 arsons, and 10 serious assaults.
There were no significant differences between patients with and without SCS in age, gender, or immigrant status. However, as expected, patients with forensic psychiatric treatment with SCS were more often convicted of a violent crime (p < 0.001).
Clinical variables
Discussion
By using a population-based total cohort of patients sentenced to forensic psychiatric treatment in a representative catchment area, this study allowed us to present key data for patients sentenced to forensic psychiatric care in Sweden. The median length of stay in this study group was just above 2.5 years (951 days). This is much shorter than lengths of stay in earlier reports from Swedish government agencies (e.g. Socialstyrelsen, 2008), but it is important to note that those earlier studies
Conflict of interest
The authors declare that they have no conflict of interest.
Acknowledgements
This work was supported by the Division of Forensic Psychiatry, Region Skåne and Lund University (under the ALF agreement). In addition, a grant from the Magnus Bergvall Foundation to TN and grants from Landstinget Kronoberg to HA, MN, and BH made the work possible. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. Nicolas Vicencio is gratefully acknowledged for his help with data collection. The authors also wish
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- 1
The first and second authors contributed equally to this work.