Mental Illness and Serious Harm to Others - University of Liverpool

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NHS National Programme on Forensic Mental Health Research and Development ❑ the 90-item Symptom Checklist (SCL-90) (Derogatis, Lipman and Covi, 1973). This has some overlap with the GHQ, but, perhaps most importantly, includes psychotic symptoms. It has been shown to be useful in a remand prison setting (Wilson, Taylor and Robertson, 1985) ❑ the Personality Disorder Questionnaire (PDQ4+) (Hyler et al, 1988), which will yield an overall indication of severity as well as some sub-classification of personality disorders along standard classification system lines (Diagnostic and Statistical Manual of Mental Disorders III R). This has been successfully applied to probationers (Dolan, Evans and Norton, 1995) and prisoners in the UK (Davison and Taylor, in press), although probably with a rather lower cut-off than Hyler originally envisaged (Davison, Leese and Taylor, 2001). It is not clear to me that such an approach would need any further research. These are validated screening instruments, but not the only ones possible, and others might do as well; there seems little justification in a project to determine which might be 'best’ in these circumstances and / or to evaluate any standardised approach to screening per se for people with mental illness. None will be acceptable to all users; there will always be some refusals. More challenging questions appear at this stage to be for policy rather than research. We know that where psychiatric need is identified among remand prisoners, length of stay in prison is likely to be prolonged. It may be that the greatest aid to identification of mental disorder would be the knowledge that something can be done about it, and done quickly if need is identified. Further discussion on such assessments is for the expert paper on mental disorder in prisons (Shaw, 2001). The other management question was intriguing: why is manic depressive disorder not treated effectively in some localities, leading to criminal convictions? My immediate response is to ask for the evidence for this statement. This is not a disorder consistently associated with offending behaviour, as the epidemiological surveys listed above indicate, although it has been noted that young adults with manic illness may commonly meet research criteria for antisocial personality disorder (Thorneloe and Crews, 1981). Perhaps a local clinical impression should lead to further inquiry locally? 4.3 Treatment questions Treatment questions focused on the effectiveness and cost implications of the atypical antipsychotic medications, and psychosocial interventions. One question, the most specific, asked about the use of structured leisure time activity in engaging people with severe and enduring mental health problems who have no other structure to their lives. By implication, filling 'idle hands' reduces their potential for violence or other antisocial behaviour. The question not posed, which might make this an important study, is about the extent and nature of imposing structure which might be counterproductive, leaving staff or carers vulnerable to assault in pressing this. Nilsson, Palmstierna and Wistedt (1998), for example, showed that among elderly inpatients, aggressive acts were most commonly directed towards nursing staff seeking to help with or maintain activities of daily living. 17
NHS National Programme on Forensic Mental Health Research and Development There are certainly grounds for extending research into the use of atypical antipsychotic medication among people with psychosis, and perhaps those without who are also seriously violent. It would be useful to know both the clinical routes by which they are effective (i.e. directly on relevant symptoms, or indirectly by their lowering distress in response to them) and the mechanisms (e.g. whether there could be a specifically anti-aggressive effect for some). It would also be important to follow people on atypical antipsychotics through the longer term: ❑ Do they remain effective in this context? ❑ Is the promise of reducing return to substance misuse fulfilled (Buckley et al, 1994)? ❑ What, if any, are the consequences of combining oral atypical antipsychotics with conventional depot medication in the longer term? 4.4 Risk questions The risk questions divided into four main groups: ❑ those simply wanting risk assessment tools and / or strategies and evaluation of these (the majority of the questions) ❑ those concerned about the theoretical underpinning of models ❑ those concerned about multidisciplinary application of risk assessment and management, and, in particular, the tensions between democracy / multiplicity and leadership / responsibility ❑ those exercised by risk management strategies. It has been argued that one of the greatest problems in risk research in this area is that it is atheoretical. That is not entirely true, in that one can sense at least emergent hypotheses such as: ❑ The antecedents of violence among people with mental illness / disorder are the same as among people without. ❑ Violence among people with mental disorder is generally attributable to that disorder. Such simplistic models, however, seem far from adequate. It is not uncommonly the case in medicine that innovations in treatment have assisted theory or hypothesis formation rather than the other way around, so the absence of adequate theory should not necessarily halt developments in this area. The case for more effort and energy going into detailed assessment schedules, however, seems weak. The important issue is what will be useful in practice on the current state of knowledge. This is likely to mean working within broad frameworks - such as the NHS Management Executive's risk management approach outlined - using broad application of what we have learned within this field more specifically. The 'domain' approach of Steadman et al (1994) seems a useful basis for a clinically 18
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Mental Illness and Serious Harm to Others - University of Liverpool

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