Prospective observational cohort study of ‘treatment as usual’ over four years for patients with schizophrenia in a national forensic hospital

Abstract

BackgroundWe evaluated change in response to multi-modal psychosocial ‘treatment as usual’ programs offered within a forensic hospital.MethodsSixty nine patients with a diagnosis of schizophrenia or schizoaffective disorder were followed for up to four years. Patient progress was evaluated using the DUNDRUM-3, a measure of patient ability to participate and benefit from multi-modal psychosocial programs and the HCR-20 dynamic items, a measure of violence proneness. We report reliable change index (RCI) and reliable and clinically meaningful change (RMC). We assessed patients’ cognition using the MCCB, psychopathology using the PANSS. The effect of cognition and psychopathology on change in DUNDRUM-3 was examined using hierarchical multiple regression with age, gender, and baseline DUNDRUM-3 scores.ResultsThe DUNDRUM-3 changed significantly (p < 0.004, d = 0.367, RCI 32% of 69 cases, RMC 23%) and HCR-20-C (p < 0.003, d = 0.377, RCI 10%). Both cognition and psychopathology accounted for significant variance in DUNDRUM-3 at follow up. Those hospitalized for less than five years at baseline changed more than longer stay patients. Mediation analysis demonstrated that the relationship between cognition and change in violence proneness (HCR-20-C) was both directly affected and indirectly mediated by change in DUNDRUM-3.ConclusionsChange in response to multi-modal psychosocial programs (DUNDRUM-3) reduced a measure of violence proneness over four years. Forensic in-patients’ ability to benefit from psychosocial treatment appears to be a function of the outcome measure used, unit of measurement employed, degree of cognitive impairment, psychopathology, and length of stay. Lower risk of re-offending may be partially attributable to participation and engagement in psychosocial interventions.

Forensic psychiatry and Covid-19: accelerating transformation in forensic psychiatry

“…Soft or subjective outcomes might include quality of life, ward atmosphere or self-reported recovery . There is evidence that psychology contributes to psychological improvement of function and reduction of risk (Richter et al 2018;, occupational therapy contributes to quality of life (O'Flynn et al 2018). But there is no evidence that multi-disciplinary team working of itself contributes anything extra to any outcome, hard or soft.…”

A randomized controlled trial of cognitive remediation for a national cohort of forensic patients with schizophrenia or schizoaffective disorder

“…Additional limitations were that medication could not be kept constant during the study, and the absence of an active control group. Additional strengths include having an appropriate dose of therapy [11, 12], the wide range of secondary outcome measures, and the ITT design.…”

“…At a minimum, this consisted of antipsychotic pharmacotherapy and a therapeutically safe and secure environment appropriate to the individual patient’s needs [11, 25, 27, 29, 30]. The system for delivering ‘treatment as usual’ has been described and shown to be effective in reducing a measure of violence proneness, the HCR-20 [11]. This draws on principles of multi-modal treatment [23] and multi-systemic treatment [24].…”

“…a level traditionally associated with moderate intellectual disability [6]. In line with systematic reviews of cognitive difficulties experienced by non-forensic patients, the cognitive impairments experienced by forensic patients are also associated with difficulties in ‘real-life’ functioning and impaired ability to benefit from psychosocial treatment programs [9–11]. Addressing the cognitive impairments experienced by forensic patients is therefore an important objective [8].…”

Outcome measures of risk and recovery in Broadmoor High Secure Forensic Hospital: stratification of care pathways and moves to medium secure hospitals

“…13 This structured professional judgement (SPJ) instrument is utilised in practice in the majority of secure forensic mental health settings in the UK, the European Union, Canada and Australia. [14][15][16][17][18] The 20 items rated in HCR-20 are statistically associated with future violence and the clinician retains the final judgement as per the SPJ methodology. 13,19 It was HCR-20-version 3 (HCR-2-V3) that was used in this study.…”