Measures in forensic psychiatry : Risk monitoring and structured outcome assessment

Background: Violent offenders suffering from a major mental disorder (MMD) are sometimes publicly portrayed as particularly dangerous. In reality however, only a small fraction of those inflicted with a MMD do commit any violent offence. The present thesis focuses on means to monitor risk of violence and to some extent measure the content and outcome of forensic psychiatric care. The overall aim of this thesis was to investigate forensic psychiatric risk assessments from a broad perspective, covering outcomes not only as violent recidivism or not. Method: Part of the work presented in this thesis (papers I and II) deals with an instrument for structured outcome measurement and community risk monitoring (SORM) used for a prospective follow-up of patients discharged from forensic psychiatric care into the community. It describes the development and testing of the SORM (paper I). By using the SORM, clinicians perceptions of which factors increase or decrease the risk of violence among out-patients is explored (paper II). Paper III explores how available patient time is used in forensic psychiatry. Paper IV describes the development of a local quality register at a forensic clinic. Results: The inter-rater reliability of the factors in SORM as measured by calculating Cohen s kappa was on average = 0.88. The SORM was also used to study clinicians perception on which factors increased or decreased the risk of violence among former forensic psychiatric patients. Most emphasis was put on: lack of insight, lack of treatment motivation, psychiatric institutional treatment, professional support contacts, and substance misuse. Least weight was given to physical healthcare, children, occupational training and employment services, partner, and impaired daily functioning. In paper III results showed that 122 different activities occurred in a forensic psychiatric clinic. The activities were grouped into 5 categories, sleep and rest, unstructured activities, daily routines, structured activities, and treatment. Average time use in the different categories was 9.07 hours of sleep and rest, 8.60 hours of unstructured activities, 4.42 hours of daily routines, 1.60 hours of structured activities, and 0.31 hours (18.6 minutes) of treatment. No significant differences in time use on treatment between subgroups of individuals characterised by diagnoses of substance use, psychotic disorders, personality disorder, or assessed as high or low violence risk were found. Paper IV reports on the development of and findings from a local quality register in forensic psychiatry. Findings from the quality register are that about 70 percent of the patients rate their quality of life as high. Also, close to 90 percent of the patients rate their health as 50 or higher on VAS-scale ranging from zero to one hundred. A further finding is that the administration of atypical anti-psychotic medication is associated with a higher BMI. Conclusions: The use of structured models for risk assessment, risk monitoring and also for measuring outcome is called for. An increase in transparency regarding measures used in forensic psychiatry with regards to both risk assessment and risk monitoring and the actual contents of the care provided is much needed to provide a basis for the furthering of research on risk factors as well as research on forensic psychiatric treatment. To widen and deepening our understanding of the process of violent recidivism, and ultimately treating major mental disorder, more data has to be gathered and analysed. Quality registers, which are called for on other grounds, could easily form a base for gathering more data and knowledge to inform risk assessment research