Penrose's law: Methodological challenges and call for data

Predicting crime during or after psychiatric care: Evaluating machine learning for risk assessment using the Danish patient registries

BACKGROUND

Structural changes in psychiatric systems have altered treatment opportunities for patients in need of mental healthcare. These changes are possibly associated with an increase in post-discharge crime, reported in the increase of forensic psychiatric populations. As current risk-assessment tools are time-consuming to administer and offer limited accuracy, this study aims to develop a predictive model designed to identify psychiatric patients at risk of committing crime leading to a future forensic psychiatric treatment course.

METHOD

We utilized the longitudinal quality of the Danish patient registries, identifying the 45.720 adult patients who had contact with the psychiatric system in 2014, of which 474 committed crime leading to a forensic psychiatric treatment course after discharge. Four machine learning models (Logistic Regression, Random Forest, XGBoost and LightGBM) were applied over a range of sociodemographic, judicial, and psychiatric variables.

RESULTS

This study achieves a F1-macro score of 76%, with precision = 57% and recall = 47% reported by the LightGBM algorithm. Our model was therefore able to identify 47% of future forensic psychiatric patients, while making correct predictions in 57% of cases.

CONCLUSION

The study demonstrates how a clinically useful initial risk-assessment can be achieved using machine learning on data from patient registries. The proposed approach offers the opportunity to flag potential future forensic psychiatric patients, while in contact with the general psychiatric system, hereby allowing early-intervention initiatives to be activated.

Changes in national rates of psychiatric beds and incarceration in Central Eastern Europe and Central Asia from 1990-2019: A retrospective database analysis

Background

Numbers of psychiatric beds (general, forensic, and residential) and prison populations have been considered to be indicators of institutionalisation of people with mental illnesses. The present study aimed to assess changes of those indicators across Central Eastern Europe and Central Asia (CEECA) over the last three decades to capture how care has developed during that historical period.

Methods

We retrospectively obtained data on numbers of psychiatric beds and prison populations from 30 countries in CEECA between 1990 and 2019. We calculated the median of the percent changes between the first and last available data points for all CEECA and for groups of countries based on former political alliances and income levels.

Findings

Primary national data were retrieved from 25 out of 30 countries. Data from international registries were used for the remaining five countries. For all of CEECA, the median decrease of the general psychiatric bed rates was 33•8% between 1990 and 2019. Median increases were observed for forensic psychiatric beds (24•7%), residential facility beds (12•0%), and for prison populations (36•0%). Greater reductions of rates of psychiatric beds were observed in countries with lower per capita income as well as in countries that were formerly part of the Soviet Union. Seventeen out of 30 countries showed inverse trends for general psychiatric beds and prison populations over time, indicating a possible shift of institutionalisation towards correctional settings.

Interpretation

Most countries had decreased rates of general psychiatric beds, while there was an increase of forensic capacities. There was an increase in incarceration rates in a majority of countries. The large variation of changes underlines the need for policies that are informed by data and by comparisons across countries.

Funding

Agencia Nacional de Investigación y Desarrollo in Chile, grant scheme FONDECYT Regular, grant number 1190613.

Negative trends in outpatient care of addicted patients in Hungary

OBJECTIVES

This article investigates how the numbers of registered addict patients have changed in the last three decades in Hungary and whether the predicted HIV epidemic among intravenous drug users has occurred.

METHODS

Data were collected from the Annual Reports of the National Bureau of Statistics and National Epidemiological Centre as well as from the medical records of the author.

RESULTS

The total number of registered alcoholics decreased by about 75% during the investigated period. This decrease was more pronounced among males than females. After initial increase, the number of registered drug addicts showed stagnation with an about 50% drop-out rate. Fortunately, the anticipated HIV epidemic did not manifest. The negative effect of a poor political action upon the number of client visits could, however, be documented.

CONCLUSION

In conclusion, negative trends are seen in the Hungarian addiction care. Numerous variables may be taken into consideration as affecting factors, but it is not yet clear to what extent these negative factors are responsible for trends. These data, however, warrant further investigations.

A brief history of the criminalization of mental illness

This article traces the history of the way in which mental disorders were viewed and treated, from before the birth of Christ to the present day. Special attention is paid to the process of deinstitutionalization in the United States and the failure to create an adequately robust community mental health system to care for the people who, in a previous era, might have experienced lifelong hospitalization. As a result, far too many people with serious mental illnesses are living in jails and prisons that are ill-suited and unprepared to meet their needs.

Incarceration rates and hospital beds per capita: A cross-national study of 36 countries, 1971-2015

RATIONALE

Incarceration carries several negative ramifications for population health, while diverting scarce resources from other public goods. At a time when health care systems around the world are strained, the current study investigates the long-term relationship between incarceration and health care infrastructure.

OBJECTIVE

We investigated the longitudinal association between incarceration rates and hospital beds per capita for 36 countries between 1971 and 2015.

METHOD

Fixed effects regression analyses were employed to examine the effect of within-country changes in incarceration rates on hospital beds per capita.

RESULTS

Findings demonstrated that increases in national incarceration rates over time were associated with declines in hospital beds per capita, net of controls for socio-demographic and economic factors.

CONCLUSIONS

Increased incarceration negatively impacts hospital bed availability at the cross-national level.

Does Penrose's Law apply to Hungary? Data of an extended survey and reappraisal

Penrose described an observation in 1939, according to which an inverse relationship between the size of prison populations and the number of psychiatric beds existed. The purpose of this article was to investigate the validity of this statement for Hungary. The national data between 1989 and 2017 for 25 variables were extracted from the official reports of the Hungarian Central Statistical Office. The number of psychiatric beds decreased by 33%, while the number of prisoners increased by about 50%. At the same time, the number of mentally ill patients under compulsive treatment was low, but showed a slight, statistically significant increase. Variables measuring similar feature, for example, the psychiatric characteristics (alcoholics registered, suicide rate, number of hospital beds, welfare home inmates) are variables consistently moving in one direction or the other that may allow finding appropriate indicators of and explanations for the phenomena. An example is the number of psychiatric beds showing a parallel decrease to the numbers of total hospital beds, registered alcoholics, out-patient clinics for children, and suicide rate, and just the opposite direction with forensic settling, involuntary admissions, and welfare home inmates. Similarly, crimes, criminals, homicides, and prisoners can also be grouped. Correlation does not mean a cause and effect relationship, therefore, at the current state of knowledge the connection among variables is not clear in all the cases. To sum up, Hungarian statistical data for three decades support Penrose's original observation on psychiatric beds and prison population, while the Penrose's statement on the inverse relationship between the number of crimes and of psychiatric beds is not supported. However, until deeper relationships are explored, aggregation of variables into few factors seems impossible.

The indistinguishables: determining appropriate environments for justice involved individuals

Criminalizing those with mental illness is a controversial topic with a long and complex history in the United States. The problem has traditionally been dichotomized between criminals (i.e., "bad") in need of placement in jails and prisons and the mentally ill (i.e., "mad") who are need of treatment in psychiatric facilities. Recent trends demonstrate significant increases in the rates of mental illness in jails and prisons, as well as increased rates of violence within psychiatric hospitals. This would suggest that there are a group of justice involved individuals who are "indistinguishable" within the traditional dichotomous categories of dangerousness and mental illness. The authors argue for a more nuanced model that dimensionally conceptualizes dangerousness and mental illness; increased attention to situational factors that create facilities appropriate for those who are dangerous and mentally ill and more diversion programs for those inappropriate for incarceration or hospitalization.

Modern forensic psychiatric hospital design: clinical, legal and structural aspects

Forensic psychiatric care must be provided within the least restrictive setting possible, whilst simultaneously maintaining appropriate levels of security. This presents particular challenges for the design of forensic psychiatric hospitals, which are required to provide both a therapeutic and a safe material environment, often for extended periods of treatment and rehabilitation. By taking into consideration variable trends in psychiatric service provision and myriad clinical, legal and ethical issues, interdisciplinary forensic facility design teams are at the very forefront in implementing the latest developments in medical architecture. Also, although there are significant differences in how forensic psychiatric services are organized around the world, the underlying clinical challenges and increasingly research-based treatment principles are similar worldwide; it is therefore becoming less acceptable to operate and develop national forensic services without reference to international standards. Accordingly, we here review the literature on what features of forensic psychiatric facilities best serve the needs of those patients who need to rely on them, and we present a systematic and widely applicable approach to the complex and costly challenge of modern forensic psychiatric hospital design.

Knocking on prison's door: a 10-fold rise in the number of psychotic prisoners in Finland during the years 2005-2016

BACKGROUND

As in many European countries, Finnish psychiatric services experienced a rapid process of deinstitutionalization in the 1990s. In recent decades, the decrease in numbers of psychiatric hospital beds has in several countries been found to be linked with increasing criminality among severely mentally ill individuals. It has been concluded that deinstitutionalization could be the main reason for this development.

AIM

To investigate whether the prevalence of severely mentally ill persons to prison is a growing trend also in Finland.

METHODS

We searched for the annual data in electronic case files of all prisoners about the ICD-10 diagnostic group of the most severe psychotic disorders. We also searched for the comorbid substance use disorders. Psychotic disorders due to substance abuse only were excluded from this study.

RESULTS

During the years 2005-2016, a rapid 10-fold increase in psychotic disorders has occurred in Finnish prisons. In 2016, 185 prisoners (5.9% of all Finnish prisoners) were diagnosed as having a psychotic disorder that was not induced by substance abuse. The causes of this dramatic change are unclear. Comorbid substance abuse disorders were detected in only 39.5% of these prisoners and therefore substance abuse can only partly explain the increasing criminality of the severely mentally ill persons. 80.5% of psychotic disorders were diagnosed in Psychiatric Hospital for prisoners and 19.5% in prison policlinic services.

CONCLUSION

Trans-institutionalization has become a serious challenge for the Finnish criminal justice and mental health systems. Further studies are needed to detect the causes of this change. More specialized services for severely mentally ill persons are needed both in the community psychiatry and also inside the prison services.