Prospective study of factors influencing conditional discharge from a forensic hospital: the DUNDRUM-3 programme completion and DUNDRUM-4 recovery structured professional judgement instruments and risk

Abstract

BackgroundWe set out to examine whether structured professional judgement instruments DUNDRUM-3 programme completion (D-3) and DUNDRUM-4 recovery (D-4) scales along with measures of risk, mental state and global function could distinguish between those forensic patients detained in a secure forensic hospital (not guilty by reason of insanity or unfit to stand trial) who were subsequently discharged by a mental health review board. We also examined the interaction between these measures and risk, need for therapeutic security and eventual conditional discharge.MethodsA naturalistic observational cohort study was carried out for 56 patients newly eligible for conditional discharge. Patients were rated using the D-3, D-4 and other scales including HCR-20, S-RAMM, START, SAPROF, PANSS and GAF and then observed over a period of twenty three months during which they were considered for conditional discharge by an independent Mental Health Review Board.ResultsThe D-3 distinguished which patients were subsequently discharged by the Mental Health Review board (AUC = 0.902, p < 0.001) as did the D-4 (AUC = 0.848, p < 0.001). Item to outcome analysis showed each item of the D-3 and D-4 scales performed significantly better than random. The HCR-20 also distinguished those later discharged (AUC = 0.838, p < 0.001) as did the S-RAMM, START, SAPROF, PANSS and GAF. The D-3 and D-4 scores remained significantly lower (better) for those discharged even when corrected for the HCR-20 total score. Item to outcome analyses and logistic regression analysis showed that the strongest antecedents of discharge were the GAF and the DUNDRUM-3 programme completion scores.ConclusionsStructured professional judgement instruments should improve the quality, consistency and transparency of clinical recommendations and decision making at mental health review boards. Further research is required to determine whether the DUNDRUM-3 programme completion and DUNDRUM-4 recovery instruments predict those who are or are not recalled or re-offend after conditional discharge.

Patient characteristics related to length of stay in Dutch forensic psychiatric care

“…Davoren et al (2015) also found that a higher DUNDRUM-1 triage security score predicted a longer LOS. Lower (better) scores in the DUNDRUM-3 program completion and DUNDRUM-4 recovery scores predicted moves to less secure settings (Davoren et al, 2012) and conditional discharge to the community (Davoren et al, 2013) as did the HCR-20 dynamic scales. Another Dutch study found that patients in LFPC are more often recidivists than patients in RFPC ( Van der Kraan, Schekman, Nijman, Hulsbos, & Bulten, 2008) which aligns with the present findings.…”

“…Validation studies have shown good psychometric qualities (Flynn, O'Neill, McInerney, & Kennedy, 2011;Freestone et al, 2015;O'Dwyer et al, 2011) and indicated that the DUNDRUM-1 items can predict the level of therapeutic security needed (Flynn et al, 2011;Freestone et al, 2015) and LOS (Davoren et al, 2015) while the DUNDRUM-3 and DUNDRUM-4 can predict moves between levels of therapeutic security (Davoren et al, 2012) and discharge (Davoren et al, 2013).…”

Predictors of Mental Health Review Tribunal (MHRT) outcome in a forensic inpatient population: a prospective cohort study

“…These studies demonstrate that with regards to demographic factors, reassuringly, neither ethnicity nor age are associated with outcome at tribunal [13, 14, 17–21]. The role of patient sex is unclear; trend-level associations reported in samples of both civil and forensic patients in both the UK and New Zealand indicate that females are more likely to be discharged than males [6, 13, 22]; however, the only previous study to have found a significant association between sex and outcome reported that males are more likely to receive discharge at tribunal than females [17].…”

“…The role of patient sex is unclear; trend-level associations reported in samples of both civil and forensic patients in both the UK and New Zealand indicate that females are more likely to be discharged than males [6, 13, 22]; however, the only previous study to have found a significant association between sex and outcome reported that males are more likely to receive discharge at tribunal than females [17]. Findings with regard to diagnosis are also mixed, Dibben and colleagues reported that when compared to patients with schizophrenia, those with mania were five times more likely to be discharged by the tribunal [23], yet other studies have observed that neither mental disorder [17, 20, 21] nor personality disorder [18] are related to outcome at MHRT. Perhaps unsurprisingly, a study conducted in a sample of maximum security inpatients in Canada reported that patients with higher psychopathy scores were significantly less likely to be discharged than those with lower scores [7].…”

“…Yet only three previous studies have attempted to explore the relationship between dynamic factors and outcome at MHRT. These studies, based in Canada and Ireland, reported that institutional management problems, treatment compliance, active psychotic symptoms, treatment success [7, 25], and scores on the Historical Clinical Risk-20 (HCR-20), a widely-used violence risk assessment tool [21], were all associated with outcome at tribunal. These findings are yet to be replicated within a UK sample and there are a number of potentially important dynamic factors, such as violent or sexually inappropriate behaviour, and leave status, which have not yet been explored in the literature.…”