Dual diagnosis and forensic care. Are the needs of service users being met?

Audit study of the new hospitalization for assessment scheme for forensic mental health in Japan

AIM: To clarify the components of hospitalization for assessment (HfA) and the management changes from the beginning of the scheme to the present.

METHODS: This study is composed of two surveys. In 2013 survey, we created two paper questionnaires (facility and case questionnaires) for psychiatrists working in psychiatric hospitals accepting HfA patients. Questionnaires were sent to 205 hospitals that were identified as accepting the HfA cases, and responses were requested via mail. The facility questionnaire was designed to clarify the following specifications and characteristics of each facility: the facility organizer (public sector or private hospital), and the number of beds, psychiatrists, psychiatric nurses, occupational therapists, psychiatric social workers, psychotherapists, public health nurses, and patients treated through HfA during the survey period. The case questionnaire was then used to collect data of the patients under HfA based on the Medical Treatment and Supervision (MTS) Act who were discharged between July 1, 2012 and June 30, 2013. Gathered information included: legal information of each case, demographic data, past history of the offenders, issued offense and the relationship to the victim, information regarding past psychiatric testimonies, psychiatric diagnoses, contents of the treatment during HfA, information regarding seclusion and restraint during the HfA, the verdict of the District Court panel, and so forth. Next, we compared those results with relevant data obtained in 2007. The 2007 survey comprised data of HfA patients from July 15, 2005 (the date the MTS Act was enforced) to January 15, 2007.

RESULTS: We obtained 171 cases, approximately a half of whole contemporary cases of HfA, from 134 facilities, of which 46 were national, prefectural, or semi-official hospitals, and 88 were private hospitals, in 2013 survey. The majority of subjects were male, schizophrenic, and experienced previous psychiatric treatment. The most frequent type of the offense was injury, followed by arson. Most of the subjects were medicated, and a few cases took psychotropic injection during the HfA. The frequency of injection was decreased in 2013 (χ² = 7.54, df = 1, P = 0.006) than in 2007. Psychiatric testimony was more likely to be conducted in 2013 (χ² = 8.56, df = 1, P = 0.004). The examiner psychiatrist was more likely to belong to the HfA facility to which the patient was hospitalized (χ² = 5.32, df = 1, P = 0.02). Hospitalization orders were more frequently selected in 2013 (χ² = 19.76, df = 3, P < 0.001), although the characteristics of the subjects had not changed.

CONCLUSION: Although the management of HfA has improved in recent years, structural problems remain.

Reasons for recall following conditional discharge: explanations given by male patients suffering from dual diagnosis in a London Forensic Unit

Patients who have been discharged from forensic services often have conditions they have to abide by as part of their discharge, and failure to do so leads to recall. We interviewed six men who had been conditionally discharged from forensic services and then been recalled into hospital to find out what they thought went wrong. The reasons they gave for why things went wrong included feeling that the system was unfair and made them feel like criminals even though they did not feel they had put anyone at risk. Some of them were not fully aware of the conditions they needed to adhere to, and some of them had breached the conditions but did not take responsibility for what had happened. In addition, supervision was felt to be very controlling and disruptive rather than supportive when patients were often lonely, bored and needing support. Most participants reported that they experienced poor standards of aftercare in hostels they were required to reside in. In the future, care of patients after conditional discharge should include better communication between patients and their supervisory team, recognition of the need for more support and improvements in the standards of care in hostels, as well as a collaborative approach to risk assessment that might reduce the frequency of relapse and readmission. This study explores how male patients suffering from dual diagnosis in a forensic unit perceive being recalled and readmitted following conditional discharge and their views about how services might be improved. A qualitative approach was used drawing on grounded theory techniques. Audiotaped semistructured interviews collected data from a purposefully selected sample of six participants who had been recalled and met the inclusion criteria of the study. Data were analysed using the constant comparative method. Most participants perceived the recall system as unfair, inappropriately criminalized their behaviour and was based on an assessment of risk that they did not understand or accept. Participants were not fully aware of the conditions of their discharge, and most did not accept responsibility for their role in being recalled and blamed the system. Care following discharge was rarely seen as positive, and poor standards in hostels were reported by most participants. Supervision was often seen as disruptive and controlling, and focused more on surveillance rather than support. Better communication might have helped them understand and adhere to the conditions of their discharge. Participants identified the importance of family and friends to their recovery, the importance of having their own accommodation, and the need to be more independent.

Variations in rates of comorbid substance use in psychosis between mental health settings and geographical areas in the UK. A systematic review

BACKGROUND

Comorbid substance misuse in psychosis is associated with significant clinical, social and legal problems. An epidemiologically informed approach to planning service delivery requires an understanding of which clinical populations are at particularly high risk for such 'dual diagnosis'. Evidence has now been accumulating in the UK since the early 1990s, and allows a relatively comprehensive comparison of rates between service settings, geographical areas and social contexts in terms of ethnic background.

METHODS

A literature search was carried out with the aim of investigating: (a) comorbid alcohol and drug misuse rates in people with established psychosis in different mental health and addiction settings in the UK, (b) variations in such rates between different population groups.

RESULTS

There are wide variations in reported drug and alcohol misuse rates in psychosis. Most recent UK studies report rates between 20 and 37% in mental health settings, while figures in addiction settings are less clear (6-15%). Rates are generally not as high as in US studies, but appear to be especially high in inpatient and crisis team settings (38-50%) and forensic settings. In terms of geography, rates appear highest in inner city areas. Some ethnic groups are over-represented among clinical populations of people with dual diagnosis.

CONCLUSIONS

Rates of substance misuse in psychosis are likely to be influenced by service setting, population composition and geography. Acute and forensic settings are especially appropriate for the development of targeted interventions.