Schizophrenia in a high-security hospital: long-term forensic,clinical, administrative & social outcomes

Objective: To determine forensic, clinical, social and administrative outcomes of high-security patients. Method: Prospective year follow-up study of 169 patients with schizophrenia, 1992–1993. Results: By the end of the study, 46 (27.2%) patients were in high security, 43 (25.5%) in medium- or low-secure units, 35 (20.7%) in an open ward, 3 (1.8%) in prison and 40 (23.7%) in the community. Violence occurred in 75% of patients over the 10-year follow-up period, and this was serious in 25%. Continuous positive symptoms of psychosis were present in over one-third. One-third had self-harmed during this period but there was only one known suicide and 11 (6.5%) deaths in total. At the end of the study, there was only one person in voluntary employment, 18 (12.7%) living independently and 10 (7.1%) in a relationship. Models were developed to determine factors relevant to these major outcomes. Conclusions: This is the first study providing comprehensive outcome data over a 10-year period. Forensic services appear good at managing the risk to the community but poor at promoting better social outcomes. The levels of violence within inpatient units are high.     

Compulsory treatment with clozapine: a retrospective long-term cohort study

BACKGROUND: Clozapine is the gold standard in treatment of treatment-resistant psychotic patients. We know little about the effects of compulsory treatment in patients unwilling to accept the necessary treatment. AIMS: To assess the effectiveness, tolerability and safety of compulsory treatment with clozapine (CTC). METHOD: A cohort of 17 consecutive patients given compulsory treatment with clozapine were rated retrospectively by their treating psychiatrists on the basis of their case notes. RESULTS: CGI-S decreased significantly over time until last observation after a mean of more than 15 months. No patient deteriorated as measured by CGI-I. At last observation as many as ten of the 11 patients still on clozapine were classified as much to very much improved. The degree of custodial restriction at last observation showed improvement in 11 patients and no change in six. No serious adverse events were observed. CONCLUSION: A trial of compulsory treatment with clozapine showed this treatment to be feasible, effective, safe and well tolerated.     

Mental Illness and Legal Fitness (Competence) to Stand Trial in New York State: Expert Opinion and Criminal Defendants' Psychiatric Symptoms,

Fitness to Stand Trial is a critical concept in the adjudication of justice‐involved persons. A retrospective study was conducted to examine criminal defendants' specific psychiatric symptoms and those symptoms' associations with expert opinions on Competence to Stand Trial. One hundred charts were reviewed: 50 Cases (opined as Not Fit) were compared against 50 Controls (opined as Fit) with respect to ratings on the Brief Psychiatric Rating Scale (BPRS). A significance level of 0.001 was selected a priori. Statistically significant differences were found in seven of the eighteen BPRS symptom constructs (with the highest differences in Conceptual Disorganization and Unusual Thought Content) and two of the four BPRS higher‐order syndrome factors (Thinking Disorder and Hostile‐Suspiciousness). Consistent with previous reports, psychotic symptoms are found in this study to be inversely associated with Fitness. Validity, reliability, and limitations of this study, as well as directions for future research, are discussed herein.