Swedish forensic psychiatry. A field in transition

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

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.

The question of sanity restoration in jail

Severe mental illness, especially psychotic disorders that are worsening, acute or complicated, normally require intensive psychiatric care and treatment that is most appropriately provided in a mental hospital. For criminal defendants, transfer to a forensic security hospital has traditionally been the means of achieving hospital care for mentally disordered defendants who have been found incompetent to stand trial or not guilty by reason of insanity. In recent years, with the shortage of intermediate and long-term hospital beds in the United States, including forensic security hospital beds, jail-based competency restoration programs are being established, seemingly obviating hospital transfer. Potential advantages of and concerns about jail-based, as opposed to hospital-based, competency restoration programs are discussed in the literature. If defendants with severe mental illness traditionally treated in a forensic security hospital for competency restoration are now treated for competency restoration in jail, it is not inconceivable that insanity acquittees could one day be treated in jail for sanity restoration. With the premise that it is better to consider the potential consequences before this becomes a serious proposal and is implemented, this analysis examine the advantages and concerns that have been put forth for jail-based competence restoration programs as they may or may not apply to jail-based sanity restoration programs. Substantial commonality is recognized, but also some differences, as well as reason for skepticism of the purported virtues of either alternative to care and treatment in forensic security hospitals.

Mortality, Rehospitalisation and Violent Crime in Forensic Psychiatric Patients Discharged from Hospital: Rates and Risk Factors

Objectives

To determine rates and risk factors for adverse outcomes in patients discharged from forensic psychiatric services.

Method

We conducted a historical cohort study of all 6,520 psychiatric patients discharged from forensic psychiatric hospitals between 1973 and 2009 in Sweden. We calculated hazard ratios for mortality, rehospitalisation, and violent crime using Cox regression to investigate the effect of different psychiatric diagnoses and two comorbidities (personality or substance use disorder) on outcomes.

Results

Over mean follow-up of 15.6 years, 30% of patients died (n = 1,949) after discharge with an average age at death of 52 years. Over two-thirds were rehospitalised (n = 4,472, 69%), and 40% violently offended after discharge (n = 2,613) with a mean time to violent crime of 4.2 years. The association between psychiatric diagnosis and outcome varied—substance use disorder as a primary diagnosis was associated with highest risk of mortality and rehospitalisation, and personality disorder was linked with the highest risk of violent offending. Furthermore comorbid substance use disorder typically increased risk of adverse outcomes.

Conclusion

Violent offending, premature mortality and rehospitalisation are prevalent in patients discharged from forensic psychiatric hospitals. Individualised treatment plans for such patients should take into account primary and comorbid psychiatric diagnoses.

History of psychiatry in Sweden during a millennium

This report covers a millennium, from year 1000 when Sweden had only 0.4 million people until today's 9.4 million. In the 13th century, the first Swedish legal text about the mentally ill and the first hospital to treat them are documented. Control, care and cure of the ill have been shaped by social and cultural changes from time to time, e.g. King Gustav Vasa introduced a paradigm shift of care after the Reformation, when he altered Catholic buildings into state hospitals. He also ordered that medical texts should no longer be written in Latin but in Swedish. The first book dealing with mental illnesses was published in 1578. Laypersons ran the mental hospitals for centuries until the medical perspective and doctors were engaged in the 1800 s. To advance the hospital doctors' competence and skill, a Swedish Psychiatric Association was established in 1905. Severely psychotic patients could not be effectively treated until the introduction of chlorpromazine in the 1950s and there is still no cure available. Following the deinstitutionalization, from more than 35,000 beds 50 years ago down to about 4500 today, the request for outpatient treatment increased. Mandatory training in psychotherapies for all psychiatrists started in the 1970s. A major "psychiatry reform", with the hope of improving the situation for the mentally ill, and to reduce the stigma, was introduced in Sweden in 1995. The historic long-term effect of the reform cannot yet be fully evaluated.

[Penrose's law: reality or fiction? Mental health system and the size of prison population - international overview]

According to the Penrose's law, outlined on the basis of a comparative study of European statistics, there is an inverse relationship between the number of psychiatric beds and prison population. Based on international data, interrelationship among prison, asylum, psychiatric disease and criminal action are investigated in the present study, paying particular attention to the event of deinstitutionalization. Prevalence of mental and addictive diseases as well as psychological disturbances in prison is characterized by epidemiological data. As proposed by Penrose, an inverse relationship between the number of psychiatric beds and prison population can be observed in Hungary, too. To get a deeper insight into the mainstream of the events, economic, sociological, philosophical, as well as therapeutic aspects initializing deinstitutionalization are highlighted in the course of analysis. On the basis of data, it can be assumed that members the same population are confined to both systems. The author arrives at the conclusion that deinstitutionalization has in fact led to trans-institutionalization, because of, on one hand, the limited capacity of community treatment facilities; on the other hand, the community treatment itself cannot provide adequate treatment options to those suffering from severe, chronic mental diseases or comorbid states. In addition, the rate of financial support and the methods for prevention and treatment are insufficient to protect patients from the effects of revolving door.

Forensic psychiatric assessment in European Union member states

OBJECTIVE

To provide a structured description and cross-boundary comparison of legal frameworks and training standards relevant for forensic psychiatric assessment in European Union member states before the extension in May 2004.

METHOD

Information on legislation and practice concerning the assessment of mentally disordered offenders was gathered by means of a detailed, structured questionnaire which was filled in by national experts.

RESULTS

Legal frameworks for the assessment and reassessment of mentally disordered offenders and professional training standards in forensic psychiatry vary markedly across EU member states.

CONCLUSION

Currently a cross-boundary harmonization of legal concepts appears hard to achieve. At least a formal construction and implementation of specialist training standards in forensic psychiatry would appear desirable.

Characteristics of spousal homicide perpetrators: a study of all cases of spousal homicide in Sweden 1990-1999

BACKGROUND

In Sweden 20 000 cases of assault against women are reported to the police every year.

METHOD

All data on the perpetrators of spousal homicide in Sweden between 1990 and 1999 were investigated (n = 164). A control group of all other perpetrators of homicide in Sweden during the same period, i.e. cases of homicide not committed in the context of spouse violence (n = 690) was used. All verdicts, as well as all material in the police investigations, including interviews with all of the police investigators, were analysed. Copies of police examinations of the suspects, and forensic reports from the autopsies, were also examined. Data on all registered criminality were collected from the National Police Register, and in cases where the perpetrators had been subject to forensic psychiatric examinations, those reports were obtained from the Swedish National Board of Forensic Medicine. In addition, the Psychopathy Checklist: Screening Version scores were rated from the forensic psychiatric examinations.

RESULTS

There was a four times higher suicide rate among the spousal homicide perpetrators (24%, n = 40) compared with the perpetrators in the control-group (6%, n = 39, chi-squared = 55,42 df = 1, p < 0.001). Consequently, suicidal ideation must be considered as an important risk factor for spousal homicide. In 79% of the cases the spousal homicide perpetrators were subject to forensic psychiatric examinations. All except 5% were diagnosed with at least one psychiatric diagnosis, and 34% were sentenced to forensic psychiatric treatment. If it is assumed that the psychiatric morbidity was high in the 24% of the perpetrators who committed suicide, then 80% of all perpetrators of spouse homicide during the study period can be characterized as mentally disordered. 'Psychopathic' perpetrators, who generally are over-represented in most violent criminality, were comparatively uncommon. Only seven (4%) in the study group met the diagnostic criteria for psychopathy as measured with the PCL:SV.

DISCUSSION

The group of spouse killers studied here fits the dysphoric/borderline group of spouse assaulters. This is a group that may benefit from treatment. Perhaps police officers could help identify this kind of spouse assaulter before a fatality occurs.