Erratum: Six Nations: a clinical scenario comparison of systems for prisoners with psychosis in Australia, Bolivia and four European nations - ERRATUM.

[This corrects the article DOI: 10.1192/bji.2022.16.].

Difference between forensic patients with schizophrenia spectrum disorders in Italy and other European countries: Results of the EU-VIORMED project.

BACKGROUND: There has been a substantial change in the law on the provision of secure health services for offender-patients in Italy, a country currently with the lowest general psychiatry bed availability per head of the population in Europe, raising questions about possible differences in offender-patient admissions between European countries. AIMS: In this multicentre case-control study, our aim was to compare the socio-demographic, clinical and criminological characteristics of a sample of Italian forensic in-patients with schizophrenia or similar psychosis with patients in a similar diagnostic range in specialist in-patient services elsewhere in Europe. METHODS: Secure hospital unit in-patients with psychosis were recruited across five European countries (Italy, Austria, Germany, Poland and England). Consenting patients were interviewed by researchers and assessed using a multidimensional standardised process. Within country similarities between Austria, Germany, Poland and England were confirmed. RESULTS: Overall, 39 Italian participants had had fewer years of education than the 182 patients in the other countries and were less likely to have ever had skilled or professional employment. The Italian patients had been older at first contact with any mental health services than the other Europeans. Diagnosed comorbidity rates were similar, but the Italian group reported higher levels of disability. Although the other European forensic patients were more likely to be undergoing treatment at the time of their index offence, they were also more likely to have been poorly compliant with treatment. The rate of suicide-related behaviours was significantly lower among the Italian patients than among the others. CONCLUSIONS: Notwithstanding similar diagnoses, important differences emerged between patients in Italian forensic mental health resident services and those in four other European countries, some possibly reflecting less access to earlier relevant services in Italy. Others, including lower disability ratings among the Italian patients and a lower rate of suicide-related behaviours, may indicate that the Italian reforms carry benefits. This is worthy of further evaluation.

RISK aversion in Italian forensic and non-forensic patients with schizophrenia spectrum disorders.

BACKGROUND: Goal-directed decision-making is a central component of the broader reward and motivation system, and requires the ability to dynamically integrate both positive and negative feedback from the environment in order to maximize rewards and minimize losses over time. Altered decision-making processes, in which individuals fail to consider the negative consequences of their decisions on both themselves and others, may play a role in driving antisocial behaviour. AIM: The main study aim was to investigate possible differences in loss and risk aversion across matched patients, all with a schizophrenia spectrum disorder (SSD), but who varied according to whether they had a history of serious interpersonal violence or not, and a sample of healthy controls with no history of violence. RESULTS: The sample included 14 forensic and 21 non-forensic patients with SSD, and 41 healthy controls. Among the three decision-making variables under investigation, risk aversion was the only significant predictor of membership of the three groups, with greater risk aversion among non-forensic patients with SSD compared to healthy controls. No differences were observed across groups in loss aversion and choice consistency. CONCLUSIONS: This evidence suggests a new potential treatment target for rehabilitative measures aimed at achieving functional improvements in patients with SSD by selectively leveraging the neuro-cognitive processing of reward.

Six nations: a clinical scenario comparison of systems for prisoners with psychosis in Australia, Bolivia and four European nations.

This paper compares across six nations the mental health systems available to prisoners with the highest acuity of psychosis and risk combined with the lowest level of insight into the need for treatment. Variations were observed within and between nations. Findings highlight the likely impact of factors such as mental health legislation and the prison mental health workforce on a nation's ability to deliver timely and effective treatment close to home for prisoners who lack capacity to consent to treatment for their severe mental illness. The potential benefits of addressing the resulting inequalities are noted.

Forensic mental health in Europe: some key figures.

PURPOSE: While the number of forensic beds and the duration of psychiatric forensic psychiatric treatment have increased in several European Union (EU) states, this is not observed in others. Patient demographics, average lengths of stay and legal frameworks also differ substantially. The lack of basic epidemiological information on forensic patients and of shared indicators on forensic care within Europe is an obstacle to comparative research. The reasons for such variation are not well understood. METHODS: Experts from seventeen EU states submitted data on forensic bed prevalence rates, gender distributions and average length of stay in forensic in-patient facilities. Average length of stay and bed prevalence rates were examined for associations with country-level variables including Gross Domestic Product (GDP), expenditure on healthcare, prison population, general psychiatric bed prevalence rates and democracy index scores. RESULTS: The data demonstrated substantial differences between states. Average length of stay was approximately ten times greater in the Netherlands than Slovenia. In England and Wales, 18% of patients were female compared to 5% in Slovenia. There was a 17-fold difference in forensic bed rates per 100,000 between the Netherlands and Spain. Exploratory analyses suggested average length of stay was associated with GDP, expenditure on healthcare and democracy index scores. CONCLUSION: The data presented in this study represent the most recent overview of key epidemiological data in forensic services across seventeen EU states. However, systematically collected epidemiological data of good quality remain elusive in forensic psychiatry. States need to develop common definitions and recording practices and contribute to a publicly available database of such epidemiological indicators.

Exploring Needs and Quality of Life of Forensic Psychiatric Inpatients in the Reformed Italian System, Implications for Care and Safety.

The Italian forensic psychiatric system underwent drastic reforms. The newly developed facilities are inspired by psychiatric community services, embracing a recovery-oriented approach. Needs and quality of life are broader concepts that consider the more rehabilitative and humanitarian aspects of treatment. In one of the new Italian forensic psychiatric services, this cross-sectional study aimed to investigate the needs and quality of life of forensic psychiatric patients. A second aim was to validate the Italian version of the Forensic inpatient Quality of Life questionnaire Short Version (FQL-SV). Overall, 42 forensic psychiatric patients were assessed using the Forensic version of the Camberwell Assessment of Need (CANFOR), the Historical-Clinical-Risk-Management-20 (HCR-20), the FQL-SV, and the World Health Organization Quality of Life (WHOQoL-Bref). Patients reported significantly fewer needs, whether met or unmet, than their treating clinicians. The general level of agreement between patients and clinicians on specific needs was low Kappa values were < .40 for 64% of the total needs and 46% of the unmet needs. Risk factors according to the HCR-20 mean scores were 13.1, 4.6, and 6.4 for the historical, clinical and risk management subscale. Quality of life was moderate to high for 74% of the patients. Our results showed that lower numbers of needs, whether reported by patients or clinicians, were associated with a better quality of life. The Italian FQL-SV had a Cronbach's alpha of 0.86 and correlated as expected with the WHOQoL-Bref. The FQL-SV is a valid and reliable tool, justifying its use for routinely assessing QoL in Italian forensic psychiatric services. This study enhances our understanding of needs and quality of life of forensic psychiatric patients and how their assessment could have an additional value for recovery-oriented treatment in forensic psychiatry. Although the detained status of forensic patients imposes real limits on the capacity for autonomy and choice, incorporating the patient's perspective on decision-making processes, in relation to aspects of treatment, care, and daily life, may have benefits such as a better treatment adherence or therapeutic alliance. Future research should clarify how routinely assessing needs and quality of life can contribute to the recovery of these forensic psychiatric patients.

The closing of forensic psychiatric hospitals in Italy: Determinants, current status and future perspectives. A scoping review.

INTRODUCTION: Italy is the only country in the world to have closed forensic psychiatric hospitals and converted to fully-residential services. The international interest around this reform has not been matched by research. This scoping review aims to report the determinants of the reform, the most updated information on how the system operates, its benefits and its challenges. We further aim to discuss the implications for policy, research and practice. METHODS: 1. Selection of relevant sources through electronic search on four databases, Google, relevant printed materials and personal communication with practitioners currently working in REMS. 2. Study quality monitoring. 3. Data extraction onto NVivo 4. Data synthesis through content analysis. RESULTS: 43 papers were selected for inclusion in our review. Two main themes were identified: 1. Historical chronology of the closure of forensic psychiatric hospitals; 2. The current model of residential forensic psychiatric care. CONCLUSIONS: The closing down of Italian forensic psychiatric hospitals represented a fundamental step for human rights. Further work is required to improve the current service, including potential reforming of the penal code, improved referral/admission processes and consistent monitoring to reduce service inequality across regions. Further research is crucial to test the effectiveness of the Italian model of care against traditional ones.

The Individual Experience of Aging Patients and the Current Service Provision in the Context of Italian Forensic Psychiatry: A Case Study.

INTRODUCTION: After the recent development of residential units for the execution of security measures managed by the National Health Service and the closing down of forensic psychiatric hospitals, no study has been conducted to investigate the individual experience of aging patients and to assess whether the new service is adequately meeting their needs. We aimed to explore the experience of the service of a sample of patients aged 50 years and above living in one of the Italian residential units for the execution of security measures. METHODS: We adopted a case study design and included a sample of five patients. We collected their basic demographic data, administered the Camberwell Assessment Needs Forensic Short Version and carried out in-depth qualitative semi-structured interviews. RESULTS: Results from the Camberwell Assessment Needs Forensic Short Version evidenced that met needs were more prevalent than unmet needs. The qualitative interviews demonstrated high levels of satisfaction around accommodation, healthcare provision, activities, availability of benefits and company, and lower levels of satisfaction around psychological and practical support. DISCUSSION: This study gave voice to aging forensic psychiatric patients and provided through personal accounts, based on their lived experience, preliminary evidence around the benefits and limitations of the Italian residential forensic psychiatric system for this age group. Implications for clinical nursing forensic practitioners operating within different service frameworks are discussed.