精神障碍医学鉴定制度设计及相关问题探究

《精神卫生法》对于精神病人合法权益的保障、社会安全防卫作用的实现具有重要意义,其不仅能为精神病患者和监护人提供非自愿住院治疗的救济渠道,在一定程度上避免“被精神病”现象的发生,同时能够保障社会公共秩序和社会公众人身安全.在对精神障碍医学鉴定的制度设计及作用进行分析的基础之上,正确辨析精神障碍医学鉴定的实施主体以及管理模式、并对精神障碍医学鉴定的实施主体、要求、委托主体等有关内容进行阐述,以期为精神障碍医学鉴定制度的良性运行提供保障.     

Mental discipline,punishment and recidivism: reading Foucault against de-radicalisation programmes in the War on Terror

This article uses Michel Foucault’s Discipline and Punish to examine how de-radicalisation programmes in the War on Terror transform power–knowledge relations, mental discipline and punishment by attempting to instil self-governance through non-violence. Foucault’s theories on the evolution of discipline and punishment can be applied to de-radicalisation programmes, but only after considerable revision. By asking questions on the nature of knowledge, practice, state involvement and recidivism of de-radicalisation, I contend that many programmes may be ultimately limited by a disproportionate focus on religious rehabilitation rather than political dialogue regarding the motivations for such violence.     

Substance use disorders in forensic psychiatric patients

There is a lack of detailed information on the role of substance use disorders (SUD) as a substantial factor in offences and treatment in forensic psychiatric patients. The aim of this study was to get a better understanding of these specifics. Clinical records of 193 male patients admitted to a Dutch forensic psychiatric hospital were scrutinized on anamnestic, diagnostic and risk assessment data. One of the central findings was that the prevalence of SUDs was high. Patients with an SUD had a more extensive criminal history, unstable and deviant lifestyle and higher risk of violent behavior than patients without a substance use disorder. No differences were found in duration of treatment, aggressive incidents and leave. Another important finding was that a distinction could be made between patients with substance use as a primary criminogenic risk factor and patients with substance use as a secondary risk factor. Although substance use is identified as a general risk factor, this study supports the idea of sub categorization of patients with an SUD and emphasizes the need for a different treatment approach. Further study is needed to identify specific treatment approaches, based on more differentiated profiles of these patients.     

Increased risk of fatal intoxication and polypharmacy among psychiatric patients at death

Patients suffering from psychiatric disorders have an excess mortality and a shorter life span expectancy compared to the general population. Furthermore, they are treated with multiple drugs and are known to have an increased risk of drug abuse. In this study, we aimed at investigating the pharmaceutical drug and drug of abuse profiles of the deceased included in the Danish prospective autopsy‐based forensic study on psychiatric patients, SURVIVE. Using the postmortem systematic toxicological analysis results, we identified 129 different consumed compounds in our population (n = 443). Polypharmacy (≥5 compounds) was detected in 39.5% of the deceased. Deceased with a psychiatric diagnosis or who died from a fatal intoxication had significantly more compounds at the time of their death compared to having either no psychiatric diagnosis or another cause of death, respectively. Evidence of drug abuse was present, as 29.8% of our total population had consumed either methadone or illicit drugs of abuse, excluding tetrahydrocannabinol. Of those deceased with a psychiatric diagnosis, 33.6% had either consumed methadone or illicit drugs of abuse, a greater number than those without a psychiatric diagnosis. Fatal intoxication was the most frequent cause of death (40.6%) with methadone as the major intoxicant. Here, we found that those without a psychiatric diagnosis had fewer fatal pharmaceutical drug intoxications compared to the psychiatric diagnosis groups. Our findings add further context to understanding the excess mortality of psychiatric patents, since there is an increased occurrence of fatal intoxication, polypharmacy, and drug abuse in this population.     

抑郁症患者盗窃案司法精神鉴定分析

本文对我院近四年来司法精神病学鉴定中16例抑郁症的盗窃案进行分析。抑郁症患者作案动机不一，以混合、不明及病理动机为主。歪曲的认知是造成患者盗窃行为的原因之一。责任能力评定应注重病情的严重程度与其犯罪行为之间有无直接因果关系。     

Neighbourhood outreach: a novel approach to Liaison and Diversion

Aims and method: We evaluate the initial outcomes from the Cornwall Criminal Justice Liaison and Diversion Service (CJLDS) which includes a pilot Neighbourhood Outreach scheme to support police with vulnerable individuals with suspected mental illness but not necessarily criminal involvement. Results: We review the first nine months’ operational data, including a six month follow-up of the initial three months’ to assess the impact of intervention. The service identified a large proportion of new cases of mental illness at an earlier stage. Intervention significantly reduced the number of contacts with police and may suggest a reduction in the severity of crime. Clinical implications: The Cornwall CJLDS with its pilot Neighbourhood Outreach has had a significant impact on both health and on crime, with additional cost savings. The degree to which this is replicable is discussed. Declaration of interest: None     

香港地区精神科中途宿舍服务及其对内地的启示

精神科中途宿舍是为精神病康复者提供的过渡性住宿服务,能帮助其通过住宿服务里的社区生活训练恢复正常生活,从而成功融入社会,是实现社区精神康复的一种新形式服务供给。文章介绍了香港地区精神科中途宿舍的发展历程及服务现状,指出其在政策、组织、理念等方面的经验优势,以及在离舍情况、专业人力、职业康复训练等方面面临的现实挑战。最后,基于香港精神科中途宿舍服务经验反思基础之上,从政策保障、组织培育、队伍建设、具体服务等方面对内地精神科中途宿舍发展提出了相关建议。     

Deinstitutionalisation and Managerialism in Queensland's Public Psychiatric Institutions: Challenging ‘Rhetoric’ with Empirical Results

This article places the experience of public psychiatric institutions for the long term mentally ill in the context of New Public Management (NPM). This managerialist school of thought has been in widespread ascendancy since the 1970s. Some key characteristics of deinstitutionalisation and NPM are outlined. We then present some historical data about the temporal process of deinstitutionalisation in Queensland's public psychiatric institutions. The time series analysis provided is of a single state since Australia's public health care system is state‐based. Although NPM is not a coherent set of principles or doctrines, it is argued that ideology and the reality may be contradicting. Some of NPM's particular emphases are empirically analysed, in particular the view that administration/management expenditures are to be reduced, while emphasising workers ‘at the coal face’. The empirical results provide no evidence of a ‘parsimonious’ approach to management: parsimony occurs only for nursing staff. Relative expenditures on managerial functions have increased.     

Deceptive behaviour and instrumental violence among psychopathic and non-psychopathic violent forensic psychiatric patients

Deceptive behaviour and instrumental violence are well-known psychopathic features and as such play important roles in the assessment of psychopathy. This study examined first, the nature of the violence committed by offenders that have been admitted to forensic psychiatric care and whether scores on the Psychopathy Checklist: Screening Version (PCL:SV), Part 1, were associated with the instrumentality of violence. Second, we examined the proneness of offenders to re-frame the instrumentality in their past violent crimes, and whether this was associated with scores on the PCL:SV. The results show that the PCL:SV, Part 1 (interpersonal/affective features), was positively related to the officially coded instrumentality of the violent crimes. As expected, this association disappeared when the instrumentality was self-reported. However, the majority of the patients tended to exaggerate the reactivity of their violent crimes when it was self-reported, indicating that most offenders, independently of level of psychopathy, used deception when questioned about the characteristics of their past violent crimes. The reasons for, and implications of, the use of deception are discussed.     

Integrating DSM-IV Factors to Predict Violence in High-Risk Psychiatric Patients

Abstract:  This study incorporated Axis-II and Axis-IV factors in DSM-IV to test the relationship between predicted risk for violence assessed in the psychiatric emergency room and actual violence during hospitalization. Psychiatric nurses lack an objective instrument to use during the acute psychiatric assessment. The retrospective study comprised consecutive psychiatric admissions ( n  = 161) in one tertiary veterans' hospital. Statistical testing for the predictive power of risk factors, relationships between variables, and violent events included nonparametric tests, factor analysis, and logistic regression. Of the 32 patients who committed violence during hospitalization, 12 had committed violence in the psychiatric emergency room. Statistical significance was shown for violent incidents and dementia, court-ordered admission, mood disorder, and for three or more risk factors. The 13-item Risk of Violence Assessment (ROVA) scale suggests validity and sensitivity for rating DSM-IV factors and psychosocial stressors to predict risk for violence during hospitalization. Replication studies are recommended to strengthen validity of the ROVA scale.