BackgroundIn this prospective study, mentally disordered perpetrators of severe violent and/or sexual crimes were followed through official registers for 59 (range 8 to 73) months. The relapse rate in criminality was assessed, compared between offenders sentenced to prison versus forensic psychiatric care, and the predictive ability of various risk factors (criminological, clinical, and of structured assessment instruments) was investigated.MethodOne hundred perpetrators were consecutively assessed between 1998 and 2001 by a clinical battery of established instruments covering DSM-IV diagnoses, psychosocial background factors, and structured assessment instruments (HCR-20, PCL-R, and life-time aggression (LHA)). Follow-up data was collected from official registers for: (i) recidivistic crimes, (ii) crimes during ongoing sanction.ResultsTwenty subjects relapsed in violent criminality during ongoing sanctions (n = 6) or after discharge/parole (n = 14). Individuals in forensic psychiatric care spent significantly more time at liberty after discharge compared to those in prison, but showed significantly fewer relapses. Criminological (age at first conviction), and clinical (conduct disorder and substance abuse/dependence) risk factors, as well as scores on structured assessment instruments, were moderately associated with violent recidivism. Logistic regression analyses showed that the predictive ability of criminological risk factors versus clinical risk factors combined with scores from assessment instruments was comparable, with each set of variables managing to correctly classify about 80% of all individuals, but the only predictors that remained significant in multiple models were criminological (age at first conviction, and a history of substance abuse among primary relatives).ConclusionsOnly one in five relapsed into serious criminality, with significantly more relapses among subjects sentenced to prison as compared to forensic psychiatric care. Criminological risk factors tended to be the best predictors of violent relapses, while few synergies were seen when the risk factors were combined. Overall, the predictive validity of common risk factors for violent criminality was rather weak.

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Aims: This prospective study was designed to replicate previous findings of an association between the platelet monoamine oxidase B (MAO-B) activity and factors of relevance for criminal behaviour in a well-documented clinical study population. Methods: Subjects (n = 77, aged 17–76 years, median 30 years) were recruited among consecutive perpetrators of severe interpersonal violent and/or sexual crimes referred to forensic psychiatric investigation. Participants were extensively investigated by structured psychiatric, psychological and social workups, including state-of-the-art rating instruments and official records, and with laboratory tests including venous blood sampling for determination of MAO-B activity. A subset of 36 individuals had lumbar punctures to measure cerebrospinal fluid concentrations of monoamine neurotransmitter metabolites. Results: Platelet MAO-B activity did not show any significant correlation with assessments of childhood behavioural disorders, substance abuse, or psychosocial adversity, nor with any crime-related factors, such as scores on the Life History of Aggression Scale, the Psychopathy Checklist or recidivistic violent crime. No significant correlation was found between MAO-B and any of the monoamine metabolites. Analyses in subgroups of smokers/non-smokers did not change this overall result. Conclusions: The findings of the present study did not support the use of MAO-B as a biological marker for aggression-related personality traits or as a predictor for violent recidivism among violent offenders.

91 Background: Although advance care planning and the completion of advance directives (ADs) are important methods to prevent unwanted aggressive care once patients have lost their decision-making capacity, only a minority of patients have ADs at the time of cancer diagnosis. Methods: We established a new multidisciplinary outpatient clinic to provide comprehensive care to patients with newly diagnosed cancer at the Inova Dwight and Martha Schar Cancer Institute in Northern Virginia. Improvement in advance care planning was chosen as one of the first quality improvement initiatives for 2015. We started the first PDSA cycle after creating the team, establishing the problem and goal statement, and reviewing the process map. We had three measures including: 1. Inquiring whether the patient has advance directives or not at the time of scheduling their first appointment, 2. Provide written information about advance directives at the patient’s first visit, 3. Obtain advance directives by the third office visit. The goal for each measure was 90%, 90%, and 50% by the end of 2015. Results: Between May-June 2015, 65 patients were evaluable. Baseline rates were 26%, 2%, and 12%, respectively for measures 1, 2, and 3. In July 2015, we convened a staff meeting to review each staff’s role in the process of advance care planning. The new patient schedulers had training and created a telephone script to effectively communicate advance directives information with patients. The front desk staff included written information about advance care planning in the new patient information folders. Clinical staff were asked to address any questions or concerns that patients have and to encourage patients to complete the ADs by next visit. After this intervention, the rates increased to 100%, 44%, and 33%, respectively for measures 1, 2, and 3 in August and September, 2015 (n = 45). Conclusions: Early discussion about the ADs for newly diagnosed cancer patients at our outpatient clinic showed improvement in the rate of completed ADs by a third office visit.