Research Shows: No Consensus on Optimal Long-Term Treatment for Forensic Patients

Nick Huband, Division of Psychiatry and Applied Psychology, University of Nottingham, UK
Vivek Furtado, Division of Psychiatry and Applied Psychology, University of Nottingham, UK
Mareike Eckert, Pompefoundation, Nijmegen, The Netherlands
Erik Bulten, Behavioural Science Institute, Radboud University, Nijmegen, The Netherlands
Birgit Vollm, Division of Psychiatry and Applied Psychology, University of Nottingham, UK

This rapid review summarizes currently available information on the definition, prevalence, characteristics, and needs of long-stay patients within forensic psychiatric settings. Sixty nine documents from 14 countries were identified. Reports on what constitutes “long-stay” and on the characteristics of long-stay patients were inconsistent. Factors most frequently associated with longer stay were seriousness of index offence, history of psychiatric treatment, cognitive deficit, severity of illness, diagnosis of schizophrenia or psychotic disorder, history of violence, and history of substance misuse. Although some countries are developing specific long-stay services, there is presently no consensus on what might constitute “best practice” in such settings.

Forensic psychiatry, length of stay, long-stay patients, mentally disordered offenders, patients’ needs

“Detention in forensic care is generally not time-limited, and discharge from a secure hospital setting will partly depend on clinical factors such as the individual’s response to treatment and the judgment of the medical team on the risk that may be associated with the patient’s discharge. In forensic settings, length of stay will also depend on the legislation around the detention of MDOs (mentally disordered offender), the complexities of service provision as well as social and political factors…It has been suggested that a significant proportion of MDOs require long term, potentially life-long, forensic psychiatric care, and that these long-stay patients are characterized by complex psychopathology, noncompliance in therapy and a high risk of criminal recidivism” (p.45).

“Although involuntary hospitalization in mental health services inevitably raises ethical issues, being by definition a coercive treatment, there are particular concerns that an extensive period of forensic inpatient care can be detrimental, seriously restricting patients’ autonomy, quality of life and their perspectives for future independent living…There is also the possibility that a significant number of long-stay forensic patients receive treatment in an inappropriate and over-restrictive care setting…” (p.46).

“The objective of this rapid review is to summarize what is currently known on the characteristics and needs of long-stay forensic inpatients…the characteristics most commonly found as positively associated with long-stay status were those which concerned the gravity of the offence that precipitated admission…These included an index offence of murder or homicide…the severity of the offence…and having an index offence that was violent…or sexually motivated…In contrast, the number of previous convictions had no significant association in 7 out of the 8 studies which tested for this…” (p.52).

“Other characteristics commonly found associated with longer forensic inpatient stays were: history of psychiatric treatment (67%), cognitive or organic deficit (67%), severity of illness or symptoms (55%), diagnosis of schizophrenia or psychotic disorder (35%); history of violence (33%), history of substance misuse (29%), poorer education (27%), and younger age at admission or index offence (26%)…Eighteen of the 40 studies used multivariate analyses to identify factors that can be considered to be predictive, rather than simply characteristic of the length of stay…the factors most often found to predict a longer length of stay were the seriousness of the index offence (severity, murder or homicide, violent, sexually motivated) and a diagnosis of schizophrenia or psychotic disorder. Having an ongoing close relationship and being employed before admission to forensic psychiatry predicted shorter stay” (p.52-53).

“…although the specific needs of long-stay forensic patients have been explored in relatively few studies, their findings may serve to guide the planning of future service provision for this patient group. Understandably, the need for safety (to others and to the self) was viewed as paramount, along with providing interventions to address violence and to resolve psychotic symptoms. Most studies also identified the need for social interaction and structured daytime activity, and the importance of providing treatment related to sex offenses and interventions to address substance abuse and physical health issues such as smoking and obesity” (p.54).

“In summary, although the literature on service provision specifically for long-stay forensic patients is sparse, continued therapeutic input for long-stay patients appears to be valued, with support for individualized treatment programs, structured activities that include sport, social, and leisure groups, and attention to work rehabilitation. An important need identified in several studies was to receive treatment for psychotic symptoms in order to achieve mental health recovery… Arguments have also been made for providing a well-lit environment to reduce aggression, for arranging for patients who are unlikely to ever be released to be cared for separately, for ensuring those with Cluster B diagnoses are kept separate from those with schizophrenia, and for adopting a high staff-to-patient ratio to avoid excessive physical security. It appears therefore that recovery, quality of life, and social climate are considered as key elements when designing provision for long-stay patients” (p.56).

“There is clearly a need for agreement on how best to define the concept of ‘long-stay’ in forensic settings. Regardless of how long-stay is defined, however, there is strong indication that development of services for this patient group should anticipate significant levels of chronic, treatment-resistant mental disorder. Future service provision for long-stay forensic patients will need to strike a balance between addressing this chronicity, reducing the risk of violence, and helping such patients achieve an improved quality of life. Whether or not such separate services for long-stay patients are needed and desirable is a question that warrants further exploration through the engagement of service users, providers, clinicians, ethicists, and law professionals” (p.57).

“A future review on this topic might benefit from a more extensive search of the grey literature for unpublished reports, and from communication with selected academic researchers and clinicians who may have personal knowledge of additional relevant studies. Including more specific search terms for qualitative research might identify studies focusing on the experience of professionals, patients, and carers of residing in forensic settings for a long period of time…The responsivity issues for long-stay patients appear poorly documented, and so good quality studies are needed of patients who do not respond to efforts to reduce their length of stay, especially in comparison with those who are more successful. Further research is also needed to evaluate newly developed long-stay forensic services…” (p.56-57).

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