Introduction The majority of homicides in society are not associated with mental illness, however there is an established association between homicide and schizophrenia. Homicide perpetrated by mentally disordered offenders is a leading reason for admission to secure forensic psychiatric hospitals. Objectives To investigate the clinical characteristics of those with a history of completed homicide in the CMH Dundrum. Methods This study was a cross sectional study of a cohort of patients in the Central Mental Hospital who had completed homicide (n=63). Results A total of 136 patients were included, 46.3% (n=63) of whom had committed homicide. Mean age of homicide perpetrators at admission was 34.6 years old (median 33.4, s.d. = 9.72). The most common diagnosis was schizophrenia (n=40, 63.5%). 73.0% (n=46) had a history of substance misuse. 36.5% (n=23) had a diagnosis of a personality disorder, including traits only. The most common victim type was a family member (n=32, 50.8%). Patients with a history of homicide had better scores on dynamic risk of violence (F=8.553, p=0.004), programme completion (F=8.258, p=0.005) and recovery (F=3.666, p=0.058) compared to non-homicide offenders, however they also had significantly longer mean length of stay, 12.7 years v 7.5 years (F=9.634,p=0.002). Conclusions Homicide perpetrators with a mental illness constitute a significant portion of the forensic mental health population and a high number of these offences were against family members. A history of homicide among forensic in-patients is associated with a longer length of stay which has implications for service development into the future.
Introduction Secure forensic mental health services have a dual role, to treat mental disorder and reduce violent recidivism. Quality of life is a method of assessing an individual patients’ perception of their own life and is linked to personal recovery. Placement in secure forensic hospital settings should not be a barrier to achieving meaningful quality of life. The WHO-QuOL measure is a self-rated tool, internationally validated used to measure patients own perception of their quality of life. Objectives This aim of this study was to assess self-reported quality of life in a complete National cohort of forensic in-patients, and ascertain the associations between quality of life and measures of violence risk, recovery and functioning. Methods This is a cross sectional study, set in Dundrum Hospital, the site of Ireland’s National Forensic Mental Health Service. It therefore includes a complete national cohort of forensic in-patients. The WHO-QuOL was offered to all 95 in-patients in Dundrum Hospital during December 2020 – January 2021, as was PANSS (Positive and Negative Symptoms for Schizophrenia Scale). During the study period the researchers collated the scores from HCR-20 (violence risk), therapeutic programme completion (DUNDRUM-3) and recovery (DUNDRUM-4). Data was gathered as part of the Dundrum Forensic Redevelopment Evaluation Study (D-FOREST). Results Lower scores on dynamic violence risk, better recovery and functioning scores were associated with higher self-rated quality of life. Conclusions The quality of life scale was meaningful in a secure forensic hospital setting. Further analysis will test relationships between symptoms, risk and protective factors and global function. Disclosure No significant relationships.
Aims We endeavoured to ascertain if using a specific tool rating insight adds benefit over and above the insight ratings on violence risk assessment or recovery based tools currently in use and to see if they may be helpful in guiding clinical decision making. Methods A cross sectional study of 104 forensic in-patients was completed. All current inpatients were rated for self-rated and clinician-rated insight using the VAGUS tool, a validated and reliable measure of insight into psychotic symptoms. All participants completed the self-rated scale independent of the clinician to avoid bias. Patients were also rated with the HCR-20, the Dundrum-3 and Dundrum-4, and the PANSS measures. Patients’ scores on the VAGUS tool and the other tools were compared to ascertain if any correlations could be identified. Results Higher scores on the VAGUS tool were associated with a greater degree of insight into psychotic symptoms. Clinician and self-ratings of insight on the VAGUS tool were different from but complimentary to the ratings for insight on the HCR-20 (r = 0.480, p = <0.001), the DUNDRUM-3 (r = 0.491, p = <0.001) and DUNDRUM-4 (r = 0.265, p = 0.041). An inverse relationship between the VAGUS scores and the scores on the PANSS measures (r = 0.452, p = <0.001) was found, correlating lower levels of insight with a higher degree of positive and negative psychotic symptoms. There was also a correlation between greater insight and progress through the care pathway to lower secure wards. Conclusion Using a specific tool to rate insight adds benefit over and above the insight ratings on other tools currently in use and may be helpful in guiding clinical decision making in the forensic setting.
Objectives In this review we examined the involuntary admissions to a purpose-built Psychiatry of Old Age (POA) specialist unit under the care of the North Dublin Psychiatry Of Old Age Service, Dublin, Ireland. Our objectives were to examine the source of referral, progress in hospital and outcomes of all involuntary admissions, under the Irish Mental Health Act, to this Psychiatry of Old Age specialist inpatient unit over a one year period. All patients were divided into two groups, those who were diagnosed with Dementia and those patients who had a functional mental illness. We specifically examined the characteristics of both groups to identify any differences their outcomes. Methods A retrospective chart review of all involuntary admissions over a one year period from January 1 st 2008 to December 31 st 2008 was conducted. Results 67% of all admissions to the Psychiatry of Old Age unit during 2008 were involuntary admissions. The detained patients were mostly male (71.4%). The most common diagnoses were Alzheimer's Dementia (38.1%), Dementia Mixed Aetiology (14.3%) and Psychotic Illness (14.3%). 88.2% of Patients who had a diagnosis of Dementia required Long Term Care at the end of their admission, but only 25% of those patients who had a Functional Mental Illness were transferred for Long Term Care at discharge. Conclusions Patients with dementia had significantly longer involuntary admissions than patients with affective or psychotic disorders. Patients with dementia were also more likely to require long-term care on discharge than those patients who did not have dementia.
Introduction Treatment resistant schizophrenia and other treatment resistant psychotic disorders are believed to be over-represented in forensic patient clusters. The true rates of treatment resistant psychoses in secure forensic hospitals remain unexplored. Objectives This study aimed to ascertain the prevalence of treatment resistant psychoses within a complete national forensic mental health service. In addition, the study sought to examine the relationships between treatment resistance for psychotic symptoms and treatment resistance in other domains, such as offending behaviour. Methods This is a cross-sectional study of a complete cohort of patients admitted to the National Forensic Mental Health Service in Ireland during the period 01/11/2021 to 31/01/2022. All inpatients at the time of the study were included. Demographic details, data appertaining to diagnosis, medication, measures of risk (HCR-20), recovery (DUNDRUM toolkit), functioning (GAF), and symptoms (PANSS) were collated. Data were gathered as part of the Dundrum Forensic Redevelopment Evaluation Study (D-FOREST). Results The sample consisted of 170 patients. Majority (n=162) 95.3% were male. The majority (n=116), 68.2%, were admitted from prisons, while a smaller number (n=35), 20.6%, were admitted from other psychiatric facilities. The insanity defense (n=94) 55.3% was the most common legal status, followed by unfit to plead (n=16) 9.4%. The commonest diagnosis was schizophrenia (n=97) 57.1%, followed by schizoaffective disorder (n=27) 15.9% and autism spectrum disorder (n=5) 2.9%. The mean age at admission was 35.52 years and the median age was 34.37 ± 9.43 SD. Of the total sample, 25.9% of patients were on more than 1000 mg per day chlorpromazine equivalent (CPZE) doses. Those whose psychotic symptoms required treatment with CPZE doses over 1000 mg per day scored poorly on DUNDRUM-3 programme completion, DUNDRUM-4 recovery scale, HCR-20 historical, HCR-20 clinical, HCR-20 risk, HCR-20 dynamic, and had poorer overall functioning (all P <0.001) than those who required lower antipsychotic doses. On binary logistic regression, correcting for age and gender, the only variable that remained significant was GAF (adjusted odds ratio = 0.979, 95% CI 0.962-0.996, P =0.014). In forward entry model regression, only the DUNDRUM-4 recovery scale (odds ratio = 1.13, 95% CI 1.07-1.19, P <0.001) and GAF (adjusted odds ratio = 0.979, 95% CI 0.962-0.996, P <0.001) were significant. This model had a robust forward and backward likelihood ratio. Conclusions Rates of treatment resistant psychoses in forensic hospital groups are indeed elevated. Overall functioning on GAF and recovery across a wide range of components in the DUNDRUM-4 scale are the best predictors of treatment resistant psychosis. Disclosure of Interest None Declared
People with major mental illness are over-represented in prison populations however there are few longitudinal studies of prison in-reach services leading to appropriate healthcare over extended periods. We aimed to examine measures of the clinical efficiency and effectiveness of a prison in-reach, court diversion and liaison service over a 3 year period. Secondly, we aimed to compare rates of identification of psychosis and diversion with rates previously reported for the same setting in the 6 years previously. We adopted a stress testing model for service evaluation. All new male remand committals to Ireland's main remand prison from 2012 to 2014 were screened in two stages. Demographic and clinical variables were recorded along with times to assessment and diversion. The DUNDRUM Toolkit was used to assess level of clinical urgency and level of security required. Binary logistic regression was used to assess factors relevant to diversion. All 6177 consecutive remands were screened of whom 1109 remand episodes (917 individuals) received a psychiatric assessment. 4.1 % (95 % CI 3.6–4.6) had active psychotic symptoms. Levels of self-harm were low. Median time to full assessment was 2 days and median time to admission was 15.0 days for local hospitals and 19.5 days for forensic admissions. Diversion to healthcare settings outside prison was achieved for 5.6 % (349/6177, 95 % CI 5.1–6.3) of all remand episodes and admissions for 2.3 % (95 % CI 1.9–2.7). Both were increased on the previous period reported. Mean DUNDRUM-1 and DUNDRUM-2 Triage Security Scores were appropriate to risk and need. We found that a two-stage screening and referral process followed by comprehensive assessment optimised identification of acute psychosis. The mapping approach described shows that it is possible for a relatively small team to sustainably achieve effective identification of major mental illness and diversion to healthcare in a risk-appropriate manner. The stress-testing structure adopted aids service evaluation and may help advise development of outcome standards for similar services.
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