Imprisonment following discharge from mental health units: A developing trend in New Zealand.

Introduction: Contemporary models of care for people with mental disorders continue to shift to community-based care, requiring fewer inpatient mental health beds, shorter inpatient lengths of stay, and less use of coercion. It has been suggested that some mentally unwell people, whose behavior can no longer be safely contained in overstretched mental health units where seclusion and restraint are discouraged, are now left to the criminal justice system to manage. It is unclear whether the risk of imprisonment following discharge from a mental health unit has increased over recent years. Methods: A quantitative, retrospective cohort study design was used to investigate any association between an acute inpatient mental health service admission in Aotearoa (New Zealand), and referral to a prison mental health team within 28 days of hospital discharge, from 2012 to 2020. Data were extracted from the national mental health dataset managed by the Ministry of Health. Results: Risk of imprisonment within 28 days of inpatient discharge increased over the study period. People experiencing this outcome were more likely to be younger, male, of Mâori or Pacific ethnicity, presenting with substance use and psychotic disorders who were aggressive or overactive, and were subject to coercive interventions such as seclusion and compulsory treatment during their admission. Discussion: We concluded that contemporary models of less coercive predominantly community based mental health care may be increasingly reliant on the criminal justice system to manage aggressive and violent behavior driven by mental illness. It is argued from a human rights perspective that mental health inpatient units should retain the capacity to safely manage this type of clinical presentation.

New justice system responses to mentally impaired defendants in New Zealand.

On 16 March 2020 the District Court in Auckland, New Zealand, had its first sitting as a court dedicated exclusively to cases where issues of fitness to stand trial or insanity had been raised. The impetus for these court sittings, called 'the CPMIP Court' [after the Criminal Procedure (Mentally Impaired Persons) Act 2003], was to reduce delays for mentally impaired defendants, and improve the coverage and efficiency of mental health advice to the Court from both Court Liaison Nurses and Health Assessors (Psychiatrists and Psychologists). This article looks at the model in operation and reflects on some early outcome data, as the possibility of further expansion of this model is contemplated in other regions. We also consider broader challenges currently facing mentally impaired defendants in New Zealand's criminal justice system, and argue that other innovative judicial approaches such as the establishment of problem-solving mental health courts should be considered.

Characteristics of Older Defendants Referred for Forensic Evaluations.

This study aimed to provide a descriptive analysis of the geriatric forensic population referred to a Regional Forensic Psychiatric Service by the court for evaluation (as inpatient, outpatient, or while incarcerated) in New Zealand, over a 7-year period. Data were collected retrospectively from forensic hospital records, including court-ordered reports for those aged 60 and older. Two-fifths (42%) of the 97 referred study subjects were diagnosed with some form of cognitive impairment such as dementia. The majority had a prior history of offending. Two-fifths (39%) were facing sexual charges, and one-third (33%) violent charges. Over one-quarter (28%) of the elderly sample was found unfit (incompetent) to stand trial. A better understanding of this group is needed to ensure forensic assessments and health and social services meet their various psychiatric needs.

Prison mental health in-reach teams in Aotearoa New Zealand: A national survey.

The STAIR in-reach model of care for prisoners with serious mental illness focuses on screening, triage, assessment, interventions and reintegration by using the principles of assertive community treatment. An evidence base exists for the efficacy for its use in Aotearoa New Zealand. However, little is known about its adoption throughout the country. This national survey of managers of in-reach teams to all prisons (N = 19) aimed to determine the pattern of in-reach service delivery. It compared STAIR in-reach teams with other teams regarding service structure, staffing, interventions, reintegration strategies and training needs. This study signals gains made by adopting the STAIR model (multi-disciplinary team service delivery, 'through the wire' support and use of technologies to assist discharge planning) and potential areas of improvement (further use of psychosocial interventions and training needs). To assist national adoption of STAIR, a review is required to consider the cultural responsivity, gender-responsivity and recovery-orientated characteristics of the model.

Comparative outcomes for a national cohort of persons convicted of murder, with and without serious mental illness, and those found not guilty by reason of insanity on a murder charge: A 25-year follow-up study.

BACKGROUND: Serious mental illness (SMI) is common among persons sentenced to life imprisonment for murder, yet little is known about how this affects rehabilitation, prospects of parole, or risk to the community. AIM: The aim of this study is to compare outcomes for a national cohort of offenders charged with murder who were either convicted and sentenced to life in prison or placed on a forensic hospital order. METHODS: The 386 cases of murder charges in New Zealand between 1988 and 2000 were divided into three groups: perpetrators without SMI sentenced to life imprisonment (n = 313), perpetrators with SMI but sentenced to life imprisonment (n = 32), or those with such illness and found not guilty by reason of insanity (NGRI) who received a forensic hospital order (n = 41). Access to rehabilitative interventions, time to release, reoffending, and recall to prison or hospital were examined. RESULTS: Being in prison but having severe mental illness delayed release on parole but did not increase the risk of criminal recidivism or recall to prison. Hospital order patients were a demographically different group; they were released to the community earlier and had a lower rate of criminal recidivism. CONCLUSIONS: This study provides some evidence that incarceration periods for life-sentenced homicide perpetrators with SMI may be reduced without increasing community risk if hospital transfer and/or more targeted interventions are provided in prison. It also provides further evidence that persons found NGRI after a charge of murder have a relatively low risk of criminal recidivism. The stigma that may sometimes attach to such offenders is unwarranted, if it relies on concerns about risk of reoffending.

Impact of an assertive community treatment model of care on the treatment of prisoners with a serious mental illness.

OBJECTIVES: This study aims to describe the impact of a mental health assertive community treatment prison model of care (PMOC) on improving the ability to identify prisoner needs, provide interventions and monitor their efficacy. METHODS: We carried out a file review across five prisons of referrals in the year before the implementation of the PMOC in 2010 ( n = 423) compared with referrals in the year after ( n = 477). RESULTS: Some improvements in the identification of needs and providing interventions were detected. There was increased use of medication management and clinically significant improvement in addressing engagement with families. Monthly multi-disciplinary team face-to-face contact improved. CONCLUSIONS: Meeting the needs of mentally ill prisoners is challenged by the complexity of the custodial environment. Improvements made resulted from changing the model of care, rather than adding new resources.

From positive screen to engagement in treatment: a preliminary study of the impact of a new model of care for prisoners with serious mental illness.

BACKGROUND: The high prevalence of serious mental illness (SMI) in prisons remains a challenge for mental health services. Many prisoners with SMI do not receive care. Screening tools have been developed but better detection has not translated to higher rates of treatment. In New Zealand a Prison Model of Care (PMOC) was developed by forensic mental health and correctional services to address this challenge. The PMOC broadened triggers for referrals to mental health teams. Referrals were triaged by mental health nurses leading to multidisciplinary team assessment within specified timeframes. This pathway for screening, referral and assessment was introduced within existing resources. METHOD: The PMOC was implemented across four prisons. An AB research design was used to explore the extent to which mentally ill prisoners were referred to and accepted by prison in-reach mental health teams and to determine the proportion of prison population receiving specialist mental health care. RESULTS: The number of prisoners in the study in the year before the PMOC (n = 9,349) was similar to the year after (n = 19,421). 24.6 % of prisoners were screened as per the PMOC in the post period. Referrals increased from 491 to 734 in the post period (Z = -7.23, p < 0.0001). A greater number of triage assessments occurred after the introduction of the PMOC (pre = 458; post = 613, Z = 4.74, p < 0.0001) leading to a significant increase in the numbers accepted onto in-reach caseloads (pre = 338; post = 426, Z = 3.16, p < 0.01). Numbers of triage assessments completed within specified time frames showed no statistically significant difference before or after implementation. The proportion of prison population on in-reach caseloads increased from 5.6 % in the pre period to 7.0 % in the year post implementation while diagnostic patterns did not change, indicating more prisoners with SMI were identified and engaged in treatment. CONCLUSIONS: The PMOC led to increased prisoner numbers across screening, referral, treatment and engagement. Gains were achieved without extra resources by consistent processes and improved clarity of professional roles and tasks. The PMOC described a more effective pathway to specialist care for people with SMI entering prison.

A prison mental health in-reach model informed by assertive community treatment principles: evaluation of its impact on planning during the pre-release period, community mental health service engagement and reoffending.

BACKGROUND: It is well recognised that prisoners with serious mental illness (SMI) are at high risk of poor outcomes on return to the community. Early engagement with mental health services and other community agencies could provide the substrate for reducing risk. AIM: To evaluate the impact of implementing an assertive community treatment informed prison in-reach model of care (PMOC) on post-release engagement with community mental health services and on reoffending rates. METHODS: One hundred and eighty prisoners with SMI released from four prisons in the year before implementation of the PMOC were compared with 170 such prisoners released the year after its implementation. RESULTS: The assertive prison model of care was associated with more pre-release contacts with community mental health services and contacts with some social care agencies in some prisons. There were significantly more post-release community mental health service engagements after implementation of this model (Z = -2.388, p = 0.02). There was a trend towards reduction in reoffending rates after release from some of the prisons (Z =1.82, p = 0.07). CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Assertive community treatment applied to prisoners with mental health problems was superior to 'treatment as usual', but more work is needed to ensure that agencies will engage prisoners in pre-release care. The fact that the model showed some benefits in the absence of any increase in resources suggests that it may be the model per se that is effective.

Capacity of forensic patients to consent to treatment.

OBJECTIVE: Lack of capacity to consent to psychiatric treatment has been promoted as a better basis for compulsion than mental disorder plus risk of harm. Previous research has examined how that legal change would affect acutely unwell inpatients. There is little research on forensic patients. This research aimed to assess capacity to consent in forensic patients at different stages of recovery and to consider the implications of respecting their competent treatment decisions. METHOD: Capacity to consent was assessed in a cross-sectional sample of 109 forensic patients both in hospital and in community settings. RESULTS: The majority of participants (67.6%) had treatment-related decision-making capacity. Very few patients with capacity refused treatment. CONCLUSIONS: Change to a capacity-based legal approach may alter treatment for some forensic patients but would not necessarily increase risk of harm to others. The implications for release decisions are less clear.

Patterns of mental health service contact before and after forensic mental health contact in New Zealand.

OBJECTIVE: To describe patterns of mental health service contact before and after contact with a regional forensic mental health service (FMHS) to assist regional mental health service planning. METHOD: All new referrals to Auckland Regional FMHS in 2006 were audited for contact with mental health services in the three years before and three years after their contact in 2006. RESULTS: A total of 925 identified individuals were referred to the Auckland Regional FMHS in 2006, predominantly through the court (81%) or prison (17%). In the preceding three years, 30.2% of these service users had no mental health service contact, 41.4% had general adult mental health service (GAMHS) contact alone, 22.6% had both FMHS and GAMHS contact, and 5.8% had FMHS contact alone. In the three years after 2006, 13.4% had no further contact with either FMHS or GAMHS, 20.3% had GAMHS contact alone, 51.2% of the sample had contact with both FMHS and GAMHS, and 15% had only FMHS contact. CONCLUSIONS: The service utilization patterns of this population support the establishment of strong links between GAMHS and FMHS in courts and prisons. Further research is needed to determine the specific models most likely to improve clinical outcomes.

Forcing family involvement in patient care: legislative and clinical issues.

OBJECTIVE: Families have an important role in the recognition and treatment of mental illness in their family members. However, the extent to which families are consulted during compulsory assessment processes has received little attention. In 2000, mandatory family/whanau consultation was introduced in New Zealand. This paper reviews the extent of family consultation during compulsory assessment and surveys clinicians' views and experience. METHOD: All applications for compulsory assessment in a representative sample of districts were audited over a 2-month period. An email survey of clinicians investigated changes in their practice since the introduction of mandatory family consultation, their views and training experiences. RESULTS: A total of 283 compulsory assessments were audited; 187 (66.1%) family/whanau consultations occurred and were completed by the assessing doctor 82.1% of the time. Of the remaining assessments, 12 did not appear consistent with the legally permitted exceptions to mandatory consultation. Some 88.6% of clinicians were aware of the legislative requirements about consultation. A significant percentage (54.7%) believed their practices had altered following legislative change. CONCLUSION: Family/whanau consultation occurred in the majority of compulsory assessments. The introduction of mandatory consultation with family/whanau may have improved clinical practice in this regard, although training and guidelines issued at a similar time are also likely to have contributed to the change in practice.

Insanity acquittee outcomes in New Zealand.

OBJECTIVE: This paper examines clinical and forensic outcomes for defendants found not guilty by reason of insanity in New Zealand, and explores the implications for policy development and clinical rehabilitation in this population. METHOD: All insanity acquittees disposed of by the courts as special patients after 1976 and released before 2004 are described. Their duration of inpatient care, rates of reconviction and rehospitalization following release are examined. The high resolution rate for violent crime reported to police suggests that reconviction rates are a reasonable proxy for violent reoffending. Factors predicting duration of inpatient care and reoffending are analysed. RESULTS: Severity of Index Offence was the only variable predicting duration of inpatient care of the 135 special patients. Offenders of more serious offences were securely detained for longer periods--averaging 6 years in the case of those charged with murder. Most patients were readmitted over the decade following discharge. Only 6% had violently reoffended 2 years after release into the community. Prior offending, age at release, ethnicity and gender predicted reoffending, but not diagnosis or duration of inpatient admission. CONCLUSIONS: Following discharge into the community, insanity acquittees are reconvicted of violent crimes at a very low rate, although readmission to hospital is common. It may be that insanity acquittees are initially detained in hospital longer than is clinically indicated, and that safe forensic community treatment can occur at an earlier stage of recovery without compromising public safety.

Mentally abnormal homicide in New Zealand as defined by legal and clinical criteria: a national study.

BACKGROUND: Homicides by people with mental illness have been studied using either clinical or legal categorization of the homicide as abnormal. No previous study has employed both definitions in the same population. METHOD: A retrospective study of all homicides in New Zealand between 1988 and 2000 considered mentally abnormal homicide using a legal definition (when the courts deemed a contribution of mental illness was present) and a clinical definition (defined as the presence of a discharge diagnosis from inpatient mental health treatment) of 'mentally abnormal'. Rates, characteristics and time trends were investigated. RESULTS: Of the 844 cases, 7.1% met legal criteria for being mentally abnormal, while 7.7% had ever received a diagnosis for a psychotic illness, and a further 14.5% had been admitted to a psychiatric hospital for any other reason. The majority (60%) of perpetrators with a psychotic diagnosis received a mental health disposition from the court. Of these, 60% were first diagnosed with their psychotic illness prior to the homicide, while 28% were first diagnosed at the time of the offence and a further 12% after imprisonment. Of all those who received a psychotic diagnosis, 89% had post-conviction admissions or a mental health disposition. CONCLUSION: Legal and clinical definitions of mentally abnormal homicide detect similar rates of mentally abnormal homicide, but illustrate somewhat different dimensions of the relationship between mental illness and homicide.

Barriers to care in severe mental illness: accounts from perpetrators of intra-familial homicide.

OBJECTIVE: To review perceptions of barriers to receiving effective mental health care described by patients who had committed intra-familial homicide in the context of untreated severe mental illness. METHOD: Semi-structured interviews addressed issues such as support, help-seeking, experience of illness, and what participants felt might have helped prevent the death(s). Transcripts were analysed for themes related to barriers to help-seeking. RESULTS: Themes identified included: hiding or minimizing difficulties, lack of knowledge or understanding of mental illness, loss of control in the context of illness, seduction by the illness, reality-distorting effects of the illness, distortion of interpersonal relationships, diminished ability to trust and difficulty acknowledging need for medication. CONCLUSIONS: Barriers to care exist at individual, interpersonal and wider societal levels and need to be addressed at all of them.

Homicide and mental illness in New Zealand, 1970-2000.

BACKGROUND: Homicides by mentally ill persons have led to political concerns about deinstitutionalisation. AIMS: To provide accurate information about the contribution of mental illness to homicide rates. METHOD: Retrospective study of homicide in New Zealand from 1970 to 2000, using data from government sources. 'Mentally abnormal homicide'perpetrators were defined as those found unfitto stand trial, not guilty by reason of insanity, convicted and sentenced to psychiatric committal, or convicted of infanticide. Group and time trends were analysed. RESULTS: Mentally abnormal homicides constituted 8.7% of the 1498 homicides. The annual rate of such homicides was 1.3 per million population, static over the period. Total homicides increased by over 6% per year from 1970 to 1990, then declined from 1990 to 2000. The percentage of all homicides committed by the mentally abnormal group fell from 19.5% in 1970 to 5.0% in 2000. Ten percent of perpetrators had been admitted to hospital during the month before the offence; 28.6% had had no prior contact with mental health services. Victims were most commonly known to the perpetrator (74%). CONCLUSIONS: Deinstitutionalisation appears not to be associated with an increased risk of homicide by people who are mentally ill.