Predicting violence in female forensic inpatients with substance use disorders - the utility of a gender-responsive assessment.

Introduction: Given that risk assessment tools are commonly based on male samples, the applicability to justice-involved women remains to be clarified. This study aimed at assessing (1) the predictive validity of the HCR-20 V3, the prevailing, yet primarily male-based violence risk assessment instrument, and (2) the incremental validity of the FAM, a gender-responsive supplement, for both inpatient violence and violent recidivism in justice-involved women. Methods: The sample included 452 female forensic inpatients with substance use disorder discharged from German forensic psychiatric care between 2001 and 2018. Results: ROC analyses revealed good predictive accuracy for the HCR-20 V3 while the FAM failed to provide incremental validity. Further, binary logistic regression determined several predictors of violence including personality disorder, covert/manipulative behavior, suicidal behavior/self-harm, and problematic intimate relationship. Discussion: These findings support the applicability of the HCR-20 V3 in justice-involved women with substance use disorder, while highlighting the clinical relevance of the FAM in supporting a gender-informed risk management.

The curse of experiencing and committing violence as a criminal recidivism predictor: A comparison between female forensic psychiatric patients with severe mental disorders and substance use disorder.

BACKGROUND: Violence occurs frequently in the life of forensic psychiatric patients, both as active aggression and in the form of victimization. Undoubtedly, these incidents shape personality, behavior, and affect the ability to interact adequately socially. Thus, such experiences may influence criminal recidivism and serve as forensic psychiatric/psychological predictors upon hospital discharge. METHODS: Hence, this study aimed at characterizing two distinct female forensic psychiatric patient populations (nonsubstance use mental disorders [n = 110] versus substance use disorder [n = 415]) regarding their active and passive violent experiences as well as contextualizing these with their individual crime recidivism rates. The analysis followed a record-based, retrospective approach. RESULTS: While both groups experienced aggression throughout childhood and youth equally often, substance use disorder patients were significantly more often exposed to violence during adulthood. On the other hand, severely mentally ill patients tended to react more often with violence during their hospital confinement. However, regarding their violent recidivism rate, no intergroup effects were observed. Finally, within the addicted group, a violent index crime as well as physical aggression during hospital confinement increased the odds for violent reoffending by approximately 2.4-fold (95% confidence interval 1.3-4.5) and 2.5-fold (95% confidence interval 1.1-5.9), respectively. CONCLUSION: In summary, these findings underline the importance of active aggression rather than victimization as an influencing factor on resocialization especially in a substance use disorder patient population.

Risk factors for violence among female forensic inpatients with schizophrenia.

Introduction: Schizophrenia is associated with a heightened risk of violent behavior. However, conclusions on the nature of this relationship remain inconclusive. Equally, the empirical evidence on female patients with schizophrenia spectrum disorders (SSD) is strongly underrepresented. Methods: For this purpose, the first aim of the present retrospective follow-up study was to determine the risk factors of violence in a sample of 99 female SSD patients discharged from forensic psychiatric treatment between 2001 and 2017, using three different measures of violence at varying time points (i.e., violent index offense, inpatient violence, and violent recidivism). Potential risk factors were retrieved from the relevant literature on SSD as well as two violence risk assessment instruments (i.e., HCR-20 V3, FAM). Further, we aimed to assess the predictive validity of the HCR-20 V3 in terms of violent recidivism and evaluate the incremental validity of the FAM as a supplementary gender-responsive assessment. Results: The given results indicate strong heterogeneity between the assessed violence groups in terms of risk factors. Particularly, violence during the index offense was related to psychotic symptoms while inpatient violence was associated with affective and behavioral instability as well as violent ideation/intent, psychotic symptoms, and non-responsiveness to treatment. Lastly, violent recidivism was related to non-compliance, cognitive instability, lack of insight, childhood antisocial behavior, and poverty. Further, the application of the HCR-20 V3 resulted in moderate predictive accuracy (AUC = 0.695), while the supplementary assessment of the FAM did not add any incremental validity. Discussion: This article provides important insights into the risk factors of violence among female SSD patients while highlighting the importance of differentiating between various forms of violence. Equally, it substitutes the existing evidence on violence risk assessment in female offenders with SSD.

Alcohol use disorder as a risk factor for violent offending and reoffending in delinquent women with substance use disorders.

Female gender is generally less associated with aggressive behavior and violent offending than male gender. Therefore, most studies on violence and (re-)offending include only men. However, it is crucial to better understand pathways to female offending in order to enable efficient psychological interventions and risk assessment in women. Well-established risk factors for aggressive behavior include alcohol use disorder (AUD) and other substance use disorders (SUDs). We retrospectively analyzed the association of AUD and other SUDs with violent offending and reoffending in a sample of female offenders (N = 334) in a forensic treatment facility. In total, 72% of the patients with an AUD had committed a violent crime leading to admission, whereas only 19% of those with other SUDs had. Over 70% of the participants with AUD had a family history of AUD, and over 83% had experienced physical violence in adulthood. Rates of AUD and other SUDs did not differ regarding aggressive behavior during inpatient treatment, while the risk of reoffending with a violent crime after discharge was nine times higher in patients with an AUD than in those with other SUDs. Our results indicate that AUD is a significant risk factor for violent offending and reoffending in women. A familial background of AUD and a history of physical abuse increase the probability for both AUD and offending, suggesting a possible interaction between (epi-)genetic and environmental factors. The comparable rates of aggression during inpatient treatment in patients with AUD and other SUDs indicate that abstinence is a protective factor for violence.

The Predictive Accuracy of the LSI-R in Female Forensic Inpatients-Assessing the Utility of Gender-Responsive Risk Factors.

Female reoffending has long been a neglected research interest. Accordingly, risk assessment instruments were developed based on the criminological knowledge of male recidivism. While feminist researchers have repeatedly criticized the failure to incorporate gender-responsive risk (GR) factors, opinions on the gender neutrality of existing instruments remain inconsistent. In order to substitute the existing literature, while extending the scope to mentally disordered offenders, the aim of the given study was the prediction of general recidivism in a sample of 525 female forensic inpatients who had been discharged from forensic psychiatric care in Germany between 2001 and 2018. Primarily, ROC analysis was conducted to assess the predictive accuracy of the LSI-R. Subsequently, separate binary logistic regression analyses were performed to determine the predictive utility of GR factors on recidivism. Lastly, multiple binary logistic regression was used to assess the incremental validity of the GR factors. The results showed that the GR factors (i.e., intimate relationship dysfunction, mental health issues, parental stress, adult physical abuse, and poverty) significantly contributed to the prediction of recidivism, while a mixed personality disorder, a dissocial personality, an unsupportive partner, and poverty added incremental validity to the predictive accuracy of the LSI-R. However, given that the added variables could only improve classification accuracy by 2.2%, the inclusion of gender-specific factors should be cautiously evaluated.

Physician assisted-dying in mentally and somatically ill individuals in Switzerland: Protocol for survey-based study.

Background: Article 115 of the Swiss Penal Code (StGB) permits physician-assisted dying (PAD), provided it is not performed for "selfish reasons," and thus, occupies a special role in international comparison. However, the Swiss federal law does not regulate who exactly is entitled to access PAD, and there is no universal agreement in the concerned professional societies. Additional uncertainty arises when assessing the wish for PAD of a mentally ill person compared to a somatically ill person. Objectives: This study aims to contribute to the discussion of PAD among the mentally ill and to provide insight into the current situation in Switzerland. Methods: This is a monocentric prospective observational survey-based study. We will conduct an exploratory online/telephone survey about PAD in somatic vs. mental illness in Switzerland. The survey sample will comprise 10,000 Swiss residents of the general population from all three language regions (German, Italian, and French) as well as 10,000 medical professionals working in the seven states ("cantons") of Basel-Stadt, Basel-Landschaft, Aargau, Lucerne, Graubünden, Ticino, and Vaud. Opinions on PAD in mentally and somatically ill patients will be assessed using 48 different case vignettes. Each participant will be randomly assigned a somatic terminal, a somatic non-terminal, and a mental non-terminal case vignette. Furthermore, the attitude toward the ethical guidelines of the Swiss Medical Association of 2004, 2018, and 2022, as well as the stigmatization of mentally ill people will be assessed. Discussion: Physician-assisted dying in mentally ill persons is a highly relevant yet controversial topic. On the one hand, mentally ill persons must not be discriminated against in their desire for PAD compared to somatically ill persons while at the same time, their vulnerability must be considered. On the other hand, treating physicians must be protected in their ethical integrity and need security when judging PAD requests. Despite its relevance, data on PAD in the mentally ill is sparse. To regulate PAD for the mentally ill, it is therefore important for Switzerland-but also internationally-to gain more insight into the ongoing debate. Clinical trial registration: ClinicalTrials.gov, identifier: NCT05492461.

A review and comparative analysis of the risk-needs-responsivity, good lives, and recovery models in forensic psychiatric treatment.

Forensic mental health care primarily focuses on aspects of safety. Treatment is involuntary, and personal rights are highly restricted. Both direct and indirect coercion and significant power imbalances can impede not only the psychological state of inpatients but also their treatment motivation and the therapeutic process in general. However, successful treatment is essential to enable patients to regain their freedom. Therefore, the question arises whether and how health professionals, without disregarding the potential risks, can enable forensic psychiatric patients to experience meaningfulness and self-efficacy in their lives. In offender rehabilitation, the Risk-Need-Responsivity (RNR) model and Good Lives Model (GLM) are widely established theories. The RNR model focuses not only on the risk of recidivism but also on those needs of a person that provoke or prevent criminal behavior and the individual's ability to respond to various kinds of interventions. In contrast, the GLM aims to reduce the risk of re-offending by enabling an individual to live a "good life," i.e., a meaningful and fulfilling life. Originally developed in correctional services, i.e., for offenders without severe mental disorders, both the RNR model and the GLM have also been tested in forensic psychiatric treatment contexts. The Recovery Model is based on the concept of personal recovery in mental health care and is understood as the development of a sense of purpose and mastery in one's own life during the process of coping with the sequelae of a mental disorder. It is a central element of rehabilitation in general, but is also being increasingly applied in forensic psychiatric treatment settings. This review aims to compare the central concepts of the three models, in particular regarding personal development, and the current evidence for their efficacy in mentally disordered offenders.

Assisted dying requests from people in detention: Psychiatric, ethical, and legal considerations-A literature review.

The principle of equivalence of care states that prisoners must have access to the same standard of health care as the general population. If, as recent court decisions suggest, assisted dying is not limited to people with a terminal physical illness or irremediable suffering, it might also be requested by people with severe mental illness in detention. Some of the countries with legal regulations on assisted dying also have recommendations on how to handle requests from prisoners. However, detention itself can lead to psychological distress and suicidality, so we must consider whether and how people in such settings can make autonomous decisions. Ethical conflicts arise with regard to an individual's free will, right to life, and physical and personal integrity and to the right of a state to inflict punishment. Furthermore, people in prison often receive insufficient mental health care. In this review, we compare different practices for dealing with requests for assisted dying from people in prison and forensic psychiatric facilities and discuss the current ethical and psychiatric issues concerning assisted dying in such settings.

Are Women Really Different? Comparison of Men and Women in a Sample of Forensic Psychiatric Inpatients.

Background: Women in detention remain a widely understudied group. Although the number of studies in women in prison has grown in the past decade, research on female forensic psychiatric inpatients has not increased, and women are in the minority in forensic psychiatry not only as patients but also as examinees. Consequently, most treatment manuals and risk assessments were developed in male samples and apply to male offenders. However, the same treatment and risk assessment rationale can be applied in male and female mentally ill offenders only if evidence shows that no relevant sex differences exist. Aims: The aim of the present study was to examine a sample of male and female forensic psychiatric inpatients with substance use disorders and to compare the socio-demographic, legal, and clinical characteristics between the sexes. Methods: The sample included 115 male and 61 female patients. All patients were in mandatory inpatient forensic psychiatry treatment according to section 64 of the German penal code. Results: We found no significant differences between men and women in terms of educational status and vocational training. However, women were more often single and less likely to be employed full time, and they reported adverse childhood experiences more often than men. Regarding clinical variables, women appeared to be less likely to have a substance use disorder due to alcohol use and had more previous psychiatric treatments than men. Male patients were significantly younger on first conviction and detention, had more criminal records and served longer total penalties than female patients. Furthermore, men committed more violent crimes and women, more narcotics-related crimes. Conclusions: The study identified sex-specific differences in forensic psychiatric patients that should be considered in the context of forensic therapy.

Efficacy of outpatient treatment of sex offenders.

The efficacy of sex offender treatment (SOT) is a matter of ongoing discussion and research in forensic psychotherapy. This study evaluates the efficacy of outpatient SOT after discharge from prison. Recidivism rates of participants treated in outpatient departments for sex offenders in Bavaria between 2008 and 2016 (treatment group, TG; n = 353) were compared with those of a matched group of released offenders without treatment (control group, CG; n = 353). The mean follow-up period was 4.5 years. The primary outcome of interest was whether the rates of reoffending differed significantly between the two groups. We compared general and specific rates of reoffending, time to reoffending, and type of reoffending. The groups differed significantly regarding the rates and time of violent reoffending and reoffending overall, but not regarding sexual reoffending respectively the type of sexual reoffending. The results indicate that outpatient SOT is effective in reducing the general but not the specific risk of reoffending.

Gender-Specific Differences in Depressive Behavior Among Forensic Psychiatric Patients.

BACKGROUND: Women are almost twice as likely to develop depression than men, but men commit suicide more often. One explanation for this paradox is that current depression inventories do not fully capture typical male symptoms of depression. Several studies showed that most depression symptoms in men are masked by externalizing behaviors, such as aggressiveness, addiction, and risky behavior. Here, we explored the differences in depression symptoms between men and women in a forensic psychiatric sample. METHODS: We screened 182 forensic psychiatric patients and selected a matched sample (21 women and 21 men). External symptoms of depression were assessed with the Gender-Sensitive Depression Screening (GSDS) and internal symptoms with the Beck Depression Inventory Revision. RESULTS: Although externalizing behaviors were similar in both groups, we found a significant relationship between external and internal depression symptoms only in men. In addition, male forensic patients with a history of suicide had higher scores in the GSDS, whereas female patients with a history of suicide had higher scores in the Beck Depression Inventory Revision. DISCUSSION: The finding that the GSDS detected depression symptoms in men indicates that this instrument might be useful for developing assessments to prevent suicide in forensic practice.

Relationship between benzodiazepine prescription, aggressive behavior, and behavioral disinhibition: a retrospective study in a Swiss prison.

BACKGROUND: Benzodiazepines are commonly prescribed in prisons amidst the controversies surrounding their potential role in causing behavioral disinhibition and aggressive behavior and their association with use and trafficking of illicit and addictive substances. The present study aimed to (1) ascertain the relationship between benzodiazepine prescription (including their dosage and duration of use) and aggressive behavior and behavioral disinhibition in prison and (2) investigate whether there was an association between benzodiazepine prescription, (including their dosage and duration of use) and using and trafficking illicit and addictive substances during imprisonment. METHODS: Data were extracted from the electronic database of an "open" Swiss prison (n = 1206, 1379 measures) over a 5-year period (2010-2015). Measures included benzodiazepine prescription, duration of benzodiazepine use and mean dosage, and punishable behaviors (physical and verbal aggression, disinhibited but not directly aggressive behaviors, property damage or theft, substance-related offenses, and rule transgression). We assessed the relationship between benzodiazepine prescription and punishable behaviors after propensity score matching. Logistic regressions were also used to test the relationship of benzodiazepine use duration and dosage with punishable behaviors among participants who received benzodiazepines. RESULTS: After propensity score matching, benzodiazepine prescription was not significantly associated with any punishable behavior. Among detained persons who took benzodiazepines, there was no significant association of dosage and duration of use with offenses involving illicit or addictive substance use or trafficking. CONCLUSIONS: Our study did not empirically support the occurrence of increased aggressive or disinhibited behaviors or increased risk of substance abuse in detained persons who received benzodiazepines in prison. This suggests a need to reconsider restrictions in prescribing benzodiazepines in the prison setting.

[The impact of religiousness on the attitude towards aggression and on aggressive behavior in a forensic-psychiatric inpatient sample]. / Der Einfluss von Religiosität auf die Einstellung gegenüber Aggression und auf aggressives Verhalten von forensisch-psychiatrischen Patienten.

AIM OF STUDY: According to previous research, religiousness might have a positive effect on the risk of delinquent behavior. This study aims to examine this correlation in a forensic-psychiatric inpatient sample. Furthermore, it compares self-reported aggression with the individuals' criminal history of violent offending. METHOD: The study sample consisted of 84 forensic patients in mandatory drug treatment according to section 64 of the German Penal Code. Religiousness and attitude towards aggressive behavior were assessed by self-report. The participants' criminal history was screened for violent offences. RESULTS: In the male forensic-psychiatric inpatient sample, higher levels of religiousness correlated negatively with the attitude towards appetitive aggression, but not with aggressive behavior. In the female sample, no significant correlation was found. CONCLUSION: We found a gender difference regarding the correlation of religiousness with the attitude towards aggression. Additionally, our results indicated a discrepancy between self-report of aggression and actual behavior in the sample of forensic-psychiatric inpatients. This might be explained by cognitive distortions, poor self-perception, or planning deficits.

Aggressive and Disruptive Behavior Among Psychiatric Patients With Major Depressive Disorder, Schizophrenia, or Alcohol Dependency and the Effect of Depression and Self-Esteem on Aggression.

Aggressive and disruptive behavior in inpatient settings poses a serious challenge for clinical staff and fellow patients. Hence, the aim of this study was to identify different aspects of aggressive and disruptive behavior in the context of an aberrant self-esteem or clinically manifested depression as potentially influencing factors. We collected self-reported data from 282 psychiatric patients [ICD-10 diagnoses for alcohol dependency, schizophrenia or major depressive disorder (MDD)] and compared it to healthy norm groups. As expected, all three patient groups scored higher in the aggression questionnaires than the norm group. Specifically, patients with MDD exhibited significantly higher externally directed aggression, reactive aggression, and irritability compared to controls. Patients with schizophrenia displayed higher irritability, while all three groups showed distinctly higher self-aggressiveness than healthy persons. We found a lower inhibition of aggression in alcohol dependent subjects compared to both the patient groups and the norm sample. Yet, the higher the self-esteem among alcohol dependent and MDD patients, the lower were their aggression scores; similarly, a lower self-esteem among patients diagnosed with schizophrenia resulted in heighten self-aggressiveness. Thus, our data suggests that therapeutic interventions for strengthening self-esteem in patients with a diagnosis of MDD, alcohol dependency or schizophrenia could reduce certain aspects of aggressive behavior. Therefore, it seems conceivable that strengthening self-esteem in psychiatric patients could contribute to the prevention of violence in clinical practice.

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.

Clinical Ethics Support Services Are Not as Well-Established in Forensic Psychiatry as in General Psychiatry.

Background: Mental health care professionals deal with complex ethical dilemmas that involve the principles of autonomy, justice, beneficence, and non-maleficence. Such dilemmas are even more prominent in forensic mental health care, where the restriction of personal rights is legitimated not only by patient well-being but also by public safety interests. Little is known about either the use of formal ethics support services or specific ethical needs in forensic mental health care. Knowledge about the current structures and how they compare with those in general psychiatry would help to identify the most important ethical issues and to analyze whether there are unmet needs that might require specific ethics support. Methods: We performed a survey study in all general psychiatric and forensic psychiatric inpatient departments in Germany. The aims were to compare the availability and functioning of clinical ethics structures and to identify specific ethical needs in inpatient forensic and general mental health care. Results: Clinical ethics support was available in 74% of general psychiatric hospitals but in only 43% of all forensic psychiatric hospitals and 25% of those offering treatment for offenders with substance use disorders. Most ethics support services were interdisciplinary. The most frequently requested retrospective and prospective ethics consultations were on issues of omission and termination of treatment, coercive measures, and advance directives. Among the hospitals without access to ethics support, 71% indicated a need for training in ethics. Discussion: Our results show that ethics consultation is well established in general psychiatry, but less so in forensic psychiatry. Mental health care professionals in forensic psychiatry seem to have a need for ethics support and training in clinical ethics. We also found a difference in access to ethics structures between hospitals that treat mentally disordered offenders and those that treat offenders with substance use disorders. Further research should focus on how ethics support can be comprehensively implemented in forensic mental health care and how this might improve treatment quality and patient and staff well-being.

Perceived Institutional Restraint Is Associated With Psychological Distress in Forensic Psychiatric Inpatients.

Background: Patients in forensic mental health care experience internal and external coercion; the latter comprises different levels of institutional restraint. These restrictions of individual freedom are mainly justified by the safety interests of third parties and are not necessarily in the patients' best interests. The effects of such a setting on mentally disordered offenders' psychological state and treatment course are not fully understood. Assessing both patients' perception of restraint and psychopathological symptoms would allow us to better understand how restraint and psychopathology interact and how they might influence treatment. Methods: In 184 forensic psychiatric inpatients, we assessed perception of institutional restraint with an adapted version of the Measuring the Quality of Prison Life (aMQPL) questionnaire and current psychological state with the Brief Symptom Checklist (BSCL) and Beck Hopelessness Scale (BHS). Results: Perceived institutional restraint (as expressed in the aMPQL subscales Transparency of procedures and decisions, Fairness, and Respect) was associated with a higher general level of psychological symptoms. Furthermore, patients who perceived a lack of institutional transparency and respect were more likely to have higher scores for hostility, depression, and suicidal ideation. We also found age and sex differences, with higher levels of psychological symptoms in younger and female patients. The diagnosis and duration of detention did not relate to perceived restraint. Discussion: Our results indicate that certain aspects of institutional restraint in long-term forensic inpatient settings correlate with certain psychological symptoms. The observed association might be explained by different kinds of factors: institutional (custodial focus), individual (self-efficacy, diagnosis, and personality), and situational (duration of detention). Although not all of these explanatory factors were addressed by the present study design, forensic mental health professionals should be aware of the relationship between perceived institutional restriction and psychopathology because it might influence treatment course and outcome.

Neuropsychological profile of pedophilic child sexual offenders compared with an IQ-matched non-offender sample - Results of a pilot study.

Child sexual offenders have been found to have a lower average IQ than the general population. Several studies indicate that they also exhibit executive dysfunction, but the specificity of this dysfunction is unclear; the inconclusive results have been attributed to methodological problems and the heterogeneity of the population. Our study aimed to describe the neuropsychological profiles of convicted child sexual offenders with pedophilia (n = 15). To control for IQ-related effects on neuropsychological performance, we compared the sample with an IQ-matched control group (n = 15). Test scores in both groups were significantly lower than the norms, but we did not find significant differences between the two study groups. The findings of our pilot study indicate that the neuropsychological deficits of pedophilic sexual offenders are unspecific rather than the result of a pedophilia-specific brain dysfunction.

Prison mental healthcare: recent developments and future challenges.

PURPOSE OF REVIEW: In prisons, resources for psychiatric care are limited, but the population is at high risk for mental disorders. This article aims to review recent findings and developments and to focus on the changing needs of prisoners and consequences for treatment. RECENT FINDINGS: The evidence for high general prevalence rates of mental disorders in prison populations can be considered as robust worldwide. Recent meta-analyses focused on specific prevalence rates and found that complex disorders, such as attention deficit hyperactivity disorder and posttraumatic stress disorder, are also more common in prison populations. Interest is growing in studying subgroups with special needs, for example, women and older prisoners. Furthermore, a large amount of research deals with suicide and self-harm, especially risk factors and assessments. Promising results have been obtained for treatment outcome in substance use disorders. Psychological therapies, however, have not yet been proven to have sustaining effects. SUMMARY: Considering the growing amount of research on prison inmates' mental health issues and heterogeneous needs, future studies should aim to consolidate previous findings and develop special diagnostic and therapeutic standards for mental healthcare in prisons that consider ethical aspects and human and financial resources.