| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| Psychiatric Bulletin | Advances in Psychiatric Treatment | All RCPsych Journals |
|
|
|
||||||||||
|
||||||||||||
Arnold Lodge, East Midlands Centre for Forensic Mental Health, Leicester
Department of Health Sciences, University of Leicester, and Arnold Lodge, East Midlands Centre for Forensic Mental Health, Leicester
Department of Psychology, University of Leicester
Division of Forensic Mental Health, University of Nottingham, Arnold Lodge and East Midlands Centre for Forensic Mental Health, Leicester, UK
Correspondence: Professor Conor Duggan, Division of Forensic Mental Health, University of Nottingham, Arnold Lodge, East Midlands Centre for Forensic Mental Health, Cordelia Close, Leicester, LE5 0LE, UK. Email: conor.duggan{at}nottshc.nhs.uk
Funding detailed in Acknowledgements.
 |
ABSTRACT |
|---|
 TOP ABSTRACT INTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
|---|
Aims To describe mortality, rates of reconviction at different time periods; violent behaviour (not leading to conviction), readmission and employment, after discharge from a medium secure unit.
Method Of 595 first admissions over a 20-year period, 550 discharged cases were followed-up. Multiple data sources were used.
Results Fifty-seven (10%) patients had died, of whom 18 (32%) died by suicide, and the risk of death was six times greater than in the general population. Almost half (49%) of those discharged were reconvicted and almost two-fifths (38%) of patients were readmitted to secure care.
Conclusions Community psychiatric services need to be aware that those discharged from medium secure care are a highly vulnerable group requiring careful follow-up if excess mortality, high levels of psychiatric morbidity and further offending are to be prevented.
|
|
INTRODUCTION |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
|---|
|
|
METHOD |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
|---|
Data sources
Admission characteristics were derived from medical records at Arnold
Lodge. Outcome data were obtained from clinical records at Arnold Lodge, other
psychiatric services, the Home Office Mental Health Unit, the Office for
National Statistics (ONS), the general practitioner registrations database,
the Offenders' Index and the Police National Computer (for reconvictions), the
electoral roll (UK-Info Disk version 10, i-CD Publishing, London, UK) and the
LexisNexis database of newspaper reports.
Outcome measures
A proforma was designed to record several outcomes, including data on
reconviction, psychiatric contact, accommodation and psychosocial variables
for each year of follow-up for each case in the study. In this paper we report
on the sample's mortality, reconviction, behaviours not resulting in
conviction, readmission to secure and open hospitals, employment and
accommodation.
Mortality
Death certificates were obtained from the ONS. The mortality of the sample
overall was compared with that of the general population by indirect
standardisation to the England and Wales mortality rates for 10-year age bands
published by the ONS
(http://www.statistics.gov.uk).
This yielded a standardised mortality ratio together with its 95% confidence
interval.
Classifying reconvictions
Although over 30 forensic follow-up studies have been published to date,
none has used the Home Office standard method for reporting reconviction. This
classifies convictions as either `grave' or `standard list' offences
(Home Office, 2002). Grave
offences are those for which the maximum sentence is life imprisonment, plus
arson not endangering life, and include murder, attempted murder, robbery,
rape and arson. Standard list offences are all other indictable offences tried
in either a Crown court or a magistrate's court. The Home Office also
standardises its reporting of reconviction, for example at 2 years and 5 years
following the date of release from prison. The authors have adopted this
classification because it allows comparison with criminal justice
statistics.
In line with Home Office practice, the date of the conviction rather than the actual date of the offence was used in the time to reconviction analyses because the date of the actual offence was not available for all offences, although it is accepted that this is a conservative approach that is likely to underestimate the rate of reoffending. The Police National Computer database provides the date when a person was charged, but this information was not available in all cases. The time to reconviction presented in the study was calculated from the point of discharge from Arnold Lodge rather than time of entering the community. However, where the case notes or reports were available, violent and aggressive episodes and fire-setting were recorded including those by patients in hospitals, prison or the community.
Ethical considerations
Ethical approval was granted from the Trent Multicentre Research Ethics
Committee. In the light of the known difficulty in both identifying and
gaining the consent of forensic psychiatric patients, the research was
conducted under section 60 of the Health and Social Care Act 2001. This
permits the use of identifiable National Health Service (NHS) patient
information under certain circumstances, without the consent of patients. This
was the first study of a psychiatric population to be granted section 60
approval. Statistical analyses were conducted using the Statistical Package
for the Social Sciences, version 11.5 for Windows.
|
|
RESULTS |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
|---|
Of the 595 first admissions, there were 502 men (84.4%) and 93 women (15.6%). Four people had died during their admission, 550 people had been discharged and 41 people had yet to be discharged at the census date. Hence, 554 `discharges' constituted the sample used in the analyses (apart from mortality, which included all admissions). The mean length of stay for this sample was 346 days (s.d.=468.2), ranging from 2 days to 3872 days. The mean age on admission was 29.9 years (s.d.=9.1). The Mental Health Act 1983 classification of these admissions comprised 67.2% mental illness, 26.6% psychopathic disorder, 3.0% mental illness and psychopathic disorder, and 0.5% mental impairment; the classification for 2.4% was unknown and 0.3% did not have a classification.
The mean length of follow-up from discharge to death, loss of contact, or the census date was 9.4 years (s.d.=4.8). Women had a longer mean follow-up time than men - 11.5 years (s.d.=4.1) and 9.0 years (s.d.=4.8) respectively (t=5.062, d.f.=144.9, P<0.001). There was no significant difference in the mean follow-up times between patients with a Mental Health Act classification of either psychopathic disorder (9.8 years, s.d.=5.1) or mental illness (9.2 years, s.d.=4.6). Overall there were 5771 person-years of follow-up from admission (including mortality on the unit) and 5246 person-years from discharge.
Discharge location
Of the 554 `discharges', 34.3% were discharged to a psychiatric hospital of
a lower security, predominantly open wards; 27.3% were discharged to the
community (which includes home or a hostel); 26.5% of patients were
transferred to the criminal justice system, either returned to prison or to
court for sentencing; 7.2% were transferred to high secure care; 2.9% were
transferred to a different medium secure unit; 0.7% died while in the unit;
and the discharge location was unknown for 1.1%, mainly due to their being
discharged in their absence after going absent without leave or failing to
return from leave.
Mortality
At the census, whether the individual was alive or dead was known for 522
of the 550 discharged patients (95%). However, 23 of the remaining 28 patients
were confirmed as being alive to at least 2000 (data from electoral rolls,
general practitioner registrations and the Police National Computer). Four
patients died during their first admission and a further 53 patients died
after discharge. The crude risk of death was 9.6% overall (9.2% for men and
14.6% for women) with a mean age at death of 43.6 years (s.d.=12.9). Only 25
deaths (44%) had a verdict of natural causes. There were 18 deaths from
suicide (32%) and 14 (25%) from other unnatural causes
(Table 1).
|
Standardised mortality ratios (SMRs) were calculated from admission rather than discharge so as to include the four individuals who died in hospital during their admission. The risks of death for men, women, the whole cohort and deaths by different causes were all significantly higher than those expected in the general population (Table 2). For instance, the risk of death was 6 times greater than expected for the whole cohort, almost 19 times greater for deaths from unnatural causes and over 32 times greater for deaths from suicide. The SMRs for the Mental Health Act legal classifications of mental illness and psychopathic disorder were 6.3 and 4.6 respectively.
|
Reconviction
Almost half (48.7%) of those discharged were reconvicted of an offence over
the entire period of follow-up (264 of 542) reconviction data for 8 patients
were missing). The locations where the offences were committed were as
follows: community 225 (85%), hospital 24 (9%) and prison 5 (2%); the location
was not known for 10 (4%). The mean time from discharge to first conviction
was 3.2 years (s.d.=3.2, median=1.9); the maximum time to conviction after
discharge was 16.4 years.
Table 3 shows the number of
patients who were convicted of a standard list or grave offence at 2 years, at
5 years and at any point during the follow-up. Patients without a conviction
but who did not have a full 2-year or 5-year follow-up were excluded. The only
significant difference for reconviction according to gender showed that men
were more likely than women to have been convicted of a standard list offence
in the first 5 years after discharge (
2=7.0, d.f.=1,
P=0.008). The only significant difference for reconviction by Mental
Health Act classification of psychopathic disorder or mental illness showed
that patients with a classification of psychopathic disorder were more likely
to have been convicted of a standard list offence at any time after discharge
(2=4.5, d.f.=1, P=0.034).
|
Violent behaviour and fire-setting after discharge
For various reasons not every offence leads to a conviction - particularly
when patients are detained in healthcare settings. Within the first 2 years
after discharge at least 28% of patients had exhibited violent behaviour not
resulting in conviction and within 5 years this had increased to at least 42%.
Within the first 2 years after discharge at least 3% of patients had engaged
in fire-setting not resulting in conviction; within 5 years this had increased
to at least 6%.
Readmission after discharge
The majority of patients in the sample were admitted to a psychiatric
hospital at some point in the follow-up. Of the 151 patients who were
discharged directly to the community, 40 (26%) were readmitted to a medium
secure unit during the follow-up. A further 152 patients (27.6%) who were
discharged to a hospital remained in hospital for the whole of the first year
after discharge, including 40 patients transferred to high secure hospitals.
Overall 20.5% were readmitted to Arnold Lodge, 7.8% to other medium secure
units and 14.9% to a high security hospital, with 207 of the 550 discharged
(37.6%) subsequently spending some time in medium or high security and with
some patients spending time in both. Over the whole study period there were
missing readmission data for 60 patients; excluding these, only 151 patients
(30.8%) were never readmitted to a psychiatric hospital.
Employment
On admission, 12.3% of patients had never been employed, and the majority
(51.3%) had been employed in unskilled jobs. Stable employment after discharge
was uncommon (14.5%) and was often provided by family members. Patients with a
Mental Health Act classification of psychopathic disorder were more likely
than patients with a classification of mental illness to have gained
employment at some point during the follow-up period. This approached
significance (2=3.7, d.f.=1, P=0.054).
|
|
DISCUSSION |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
|---|
Limitations
The first major limitation was that this study examined the outcome from a
single unit; with its unique policies and therapeutic ethos; hence its results
may not be generalisable to all medium secure units. What is needed now is
similar reports from other medium secure units with which these findings can
be compared. The other major follow-up study
(Maden et al, 1999)
was based on the Dennis Hill Unit, which largely concentrated on
rehabilitating patients from high security. Arnold Lodge itself was also
unique among medium secure units in that it provided a dedicated treatment
service for individuals with a diagnosis of personality disorder
(McMurran et al,
1998). Although this is important in providing information on the
course of such individuals after discharge, the impact of this group is
unlikely to feature in other units. An additional limitation, as with any
long-term follow-up, is that these outcome data reflect the therapeutic
practice and policies of Arnold Lodge at the time; these have changed
substantially over 20 years. Most importantly, the major factor influencing
long-term outcome is likely to be the care patients received after discharge.
This varied geographically across the region, from well-established community
forensic services to poorly developed services relying on a series of locum
consultants. There have also been major changes over time in treatment: for
example the use of atypical antipsychotic medication and the availability of
assertive outreach services, which might be expected to have a positive impact
on an individual's course, were only in evidence towards the end of the study.
However, these are criticisms that can be levelled at any long-term follow-up
study (Stone, 1990).
While acknowledging these limitations, it is also important to point to a major advantage of the study. Section 60 approval meant that patient ascertainment was high, as patients' consent to follow-up was not required. This is important in a group containing a large number of individuals with antisocial tendencies, where it is generally accepted that it is difficult to obtain such consent (Paris, 2003), and that if there is an ascertainment bias those who consent to be studied are likely to have the better outcome. The use of multiple data sources in our study also improved accuracy and reduced attrition (Friendship et al, 2001; Francis et al, 2002).
Mortality
One of the most striking findings of this study was that a six-fold
increase in mortality compared with the general population compares
unfavourably with rates reported for other psychiatric groups. For instance,
Harris & Barraclough (1998)
in a major review reported SMRs of 156 and 141 respectively for men and women
with schizophrenia and 184 for those with personality disorder. Similarly, a
general psychiatry first admission sample (using a similar method of
recruitment to our study) had an SMR of 136, which was not significantly
raised compared with the general population, and no suicide, despite an almost
complete follow-up over 16 years (Naik
et al, 1997). A study of deaths in 1996-1997 among
ex-prisoners, offenders on community sentences and prisoners reported SMRs of
276, 358 and 150 (Sattar,
2001). Thus, our sample had a significantly greater mortality than
other psychiatric and criminal justice samples, and it may therefore be a
genuinely `high-risk' population in terms of suicide and unnatural death (for
further discussion see Davies et
al, 2001).
Death, particularly from suicide, represents the end-point of a number of complex and long-term processes. Following their first admission to a medium secure unit patients will have had a variety of experiences; many will have continued to receive psychiatric services; and some will have remained as in-patients over the entire period of follow-up. Some patients will have returned to the criminal justice system with no further psychiatric contact; others will have been discharged or lost to follow-up in the community. The vast majority will continue to experience mental disorder with its long-term risk of suicide and increased mortality. In addition these people will carry the stigma of previous offending, and many will be convicted of further offences; to this will be added further risk factors such as difficulties in obtaining employment, finding accommodation and maintaining social networks, resulting in poverty and social exclusion. Factors detrimental to physical health such as obesity, lack of exercise, smoking and the side-effects of antipsychotic medication (such as diabetes and cardiac arrhythmias) are also common in psychiatric populations. The message for general psychiatric services that will in the main be responsible for such patients is that this population's risks of mortality are high, probably related to psychiatric illness, treatment and lifestyle, and that all of these problems need to be addressed, as well as risks to others.
Reconviction
A methodological strength of our study was the use of multiple sources to
minimise attrition and corroborate conviction data. Although the rates of
conviction could be considered to be high, they are less than those found in
other criminological samples. For instance, about a quarter (26%) of this
sample were convicted of a standard list offence within 2 years of discharge
(or 30% of those discharged directly to the community), compared with the 58%
of prisoners released in 2001 who were reconvicted of a standard list offence
within 2 years (Home Office,
2002). Reducing reoffending is difficult as the criminal justice
system has discovered, with several initiatives and legislation only
succeeding in reducing reoffending in England and Wales by 1.3% between 1997
and 2001 (Home Office, 2006).
The lowest rates of reconviction are for those with the longest periods of
detention and closest supervision, namely life-sentenced prisoners and
restricted patients. The reconviction rates for standard list and grave
offences at 5 years (for those with previous convictions) are 17% and 3% for
restricted patients and 10% and 1% for life licences respectively
(Kershaw et al, 1997).
However, many discharged patients were also involved in violent incidents or
acts of arson (42% and 6% respectively at 5 years) for which they were not
charged or convicted.
An important outcome for those who provide community psychiatric services is the number of serious offences - especially homicide, inquiries following which have done so much to shape mental health policy. In this follow-up, five men were convicted of manslaughter during the study period, with one being convicted of two counts of attempted murder in addition to his conviction of manslaughter. All five offences took place in the community. Four patients had a Mental Health Act classification of mental illness and one had a classification of mental illness and psychopathic disorders. The duration from discharge to the offence varied from 3 months to over 9 years.
Although the outcome for reoffending was generally poor, there were two positive findings. The first was that although there is evidence that the level of risk among those admitted to medium secure units has increased, there has not been an increase in the rate of reconviction over time. Reconviction rates were analysed comparing patients discharged during the first 10 years of the study with those discharged during the last 10 years of the study: there was no significant difference in the numbers of patients reconvicted of standard list or grave offences at 2 years or 5 years. The second encouraging finding, in contrast to previous studies (e.g. Steels et al, 1998), was that those with a classification of psychopathic disorder did not have a significantly higher rate of reconviction than those with a classification of mental illness.
Employment
Employment is an important and tangible factor in the quality of living.
Mentally disordered offenders are doubly censured, as both mental disorder and
criminal history can be barriers to gaining employment. Patients who enter
medium secure care often have limited experience of employment and a lower
than average standard of education. Our finding that patients with a Mental
Health Act classification of psychopathic disorder were more likely than
patients with a classification of mental illness to have gained employment at
some point during the follow-up is in line with previous research
(Steels et al,
1998).
Implications of the study
Overall the long-term outcome for former patients from the medium secure
unit in this study was poor, with excess mortality, high rates of reconviction
and readmission, and few gaining employment. Advances in mental health
provision will, we hope, have a positive impact on an individual's course in
future years. For community services, particularly assertive outreach,
community forensic and community mental health teams, the message must be that
risk in terms of mortality, morbidity and harm to others remains high in this
population over long periods. Follow-up care needs to be consistent and
long-term, and information on risk should not be lost or overlooked - an
increasingly difficult task with the multiplicity of teams and continual
reorganisation of psychiatric services.
|
|
ACKNOWLEDGMENTS |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
|---|
|
|
REFERENCES |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
|---|
Francis, B., Crosland, P. & Harman, J. (2002) The Police National Computer and the Offenders Index: can they be combined for research purposes? Home Office Research Findings 170. Home Office Research, Development and Statistics Directorate.
Friendship, C., Thornton, D., Erikson, M., et al (2001) Reconviction: a critique and comparison of two main data sources in England and Wales. Legal and Criminological Psychology, 6, 121 -129.[CrossRef]
Harris, E. C. & Barraclough, B. (1998)
Excess mortality of mental disorder. British Journal of
Psychiatry, 173, 11
-53.
Home Office (2002) Criminal Statistics, England and Wales 2001. Cm 5696. TSO (The Stationery Office).
Home Office (2006) A Five-Year Strategy for Protecting the Public and Reducing Offending. TSO (The Stationery Office).
Kershaw, C., Dodswell, P. & Goodman, J. (1997) Restricted Patients: Reconvictions and Recalls by the End of 1995: England and Wales. Home Office Research, Development and Statistics Directorate.
Maden, A., Rutter, S., McClintock, T., et al
(1999) Outcome of admission to a medium secure psychiatric
unit: I. Short- and long-term outcome. British Journal of
Psychiatry, 175, 313
-316.
Maden, A., Scott, F., Burdett, R., et al
(2004) Offending in psychiatric patients after discharge from
medium secure units: prospective national cohort study.
BMJ, 328, 1534
.
McMurran, M., Egan, V., & Ahmadi, S. (1998) A retrospective evaluation of a therapeutic community for mentally disordered offenders. Journal of Forensic Psychiatry, 9, 103-114.
Naik, P. C., Davies, S., Buckley, A. M., et al
(1997) Long-term mortality after first psychiatric admission.
British Journal of Psychiatry,
170, 43-46.
Paris, J. (2003) Personality Disorders Over Time: Precursors, Course and Outcome. American Psychiatric Publishing.
Ricketts, D., Carnell, H., Davies, S., et al (2001) First admissions to a regional secure unit over a 16-year period: changes in demographic and service characteristics. Journal of Forensic Psychiatry, 12, 78-89.
Sattar, G. (2001) Rates and Causes of Death Amongst Prisoners and Offenders under Community Supervision. Home Office Research Study 231. Home Office Research, Development and Statistics Directorate.
Steels, M., Roney, G., Larkin, E., et al (1998) Discharged from special hospital under restrictions: a comparison of the fates of psychopaths and the mentally ill. Criminal Behaviour and Mental Health, 8, 39-55.[CrossRef]
Stone, M. (1990) The Fate of Borderline Patients: Successful Outcome and Psychiatric Practice. Guilford.
Received for publication July 28, 2006. Revision received December 19, 2006. Accepted for publication January 19, 2007.
Related articles in BJP:
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| Psychiatric Bulletin | Advances in Psychiatric Treatment | All RCPsych Journals |
