Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.
ADVANCED SEARCH
Log in
Top
BMC Psychiatry
Published in: BMC Psychiatry 1/2018

Open Access 01-12-2018 | Research article

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

Authors: Melanie S. Richter, Ken O’Reilly, Danny O’Sullivan, Padraic O’Flynn, Aiden Corvin, Gary Donohoe, Ciaran Coyle, Mary Davoren, Caroline Higgins, Orla Byrne, Tina Nutley, Andrea Nulty, Kapil Sharma, Paul O’Connell, Harry G. Kennedy

Published in: BMC Psychiatry | Issue 1/2018

Login to get access

Abstract

Background

We evaluated change in response to multi-modal psychosocial ‘treatment as usual’ programs offered within a forensic hospital.

Methods

Sixty 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.

Results

The 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.

Conclusions

Change 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.
Literature
1.
McFadyen JA. Safe, sound and supportive: forensic mental health services. Br J Nurs. 1999;8:1436–40.CrossRefPubMed
2.
Kennedy HG. Therapeutic uses of security: mapping forensic mental health services by stratifying risk. Adv Psychiatr Treat. 2002;8:433–43.CrossRef
3.
Fazel S, Fimińska Z, Cocks C, Coid J. Patient outcomes following discharge from secure psychiatric hospitals: systematic review and meta-analysis. Br J Psychiatry. 2016;208:17–25.CrossRefPubMedPubMedCentral
4.
Leucht S, Leucht C, Huhn M, Chaimani A, Mavridis D, Helfer B, Samara M, Rabaioli M, Bächer S, Cipriani A, Geddes JR, Salanti G, Davis JM. Sixty years of placebo-controlled antipsychotic drug trials in acute schizophrenia: systematic review, Bayesian Meta-analysis, and Meta-regression of efficacy predictors. Am J Psychiatr 2017; May 25:appiajp201716121358. doi: https://​doi.​org/​10.​1176/​appi.​ajp.​2017.​16121358.
5.
Xia J, Merinder LB, Belgamwar MR. Psychoeducation for schizophrenia. Cochrane Database Syst Rev. 2014. Author manuscript; available in PMC 2014 Sep 22. Cochrane Database Syst Rev. 2011 Jun 15;(6):CD002831. doi: https://​doi.​org/​10.​1002/​14651858.CD002831.pub2.
6.
Rezansoff SN, Moniruzzaman A, Fazel S, McCandless L, Somers JM. Adherence to antipsychotic medication and criminal recidivism in a Canadian provincial offender population. Schizophr Bull 2017;43:1002–1010. Published online 2017 Jun 20. doi: https://​doi.​org/​10.​1093/​schbul/​sbx084
7.
García S, Martínez-Cengotitabengoa M, López-Zurbano S, Zorrilla I, López P, Vieta E, González-Pinto A. Adherence to antipsychotic medication in bipolar disorder and schizophrenic patients: a systematic review. J Clin Psychopharmacol. 2016;36:355–71.CrossRefPubMedPubMedCentral
8.
Gilmer TP, Dolder CR, Lacro JP, Folsom DP, Lindamer L, Garcia P, Jeste DV. Adherence to treatment with antipsychotic medication and health care costs among Medicaid beneficiaries with schizophrenia. Am J Psychiatr. 2004;161:692–9.CrossRefPubMed
9.
Green MF, Kern RS, Braff DL, Mintz J. Neurocognitive deficits and functional outcome in schizophrenia: are we measuring the "right stuff"? Schizophr Bull. 2000;26:119–36.CrossRefPubMed
10.
Hildebrand M, de Ruiter C. Psychopathic traits and change on indicators of dynamic risk factors during inpatient forensic psychiatric treatment. Int J Law Psychiatry. 2012;35:276–88.CrossRefPubMed
11.
Kurtz MM. Neurocognition as a predictor of response to evidence-based psychosocial interventions in schizophrenia: what is the state of the evidence? Clin Psychol Rev. 2011;31:663–72.CrossRefPubMedPubMedCentral
12.
Cullen AE, Clarke AY, Kuipers E, Hodgins S, Dean K, Fahy T. A multisite randomized trial of a cognitive skills program for male mentally disordered offenders: violence and antisocial behavior outcomes. J Consult Clin Psychol. 2012;80:1114–20.CrossRefPubMed
13.
14.
O'Reilly K, O'Connell P, Donohoe G, Coyle C, O'Sullivan D, Azvee Z, Maddock C, Sharma K, Sadi H, McMahon M, Kennedy HG. Anticholinergic burden in schizophrenia and ability to benefit from psychosocial treatment programmes: a 3-year prospective cohort study. Psychol Med. 2016;46:3199–211.CrossRefPubMed
15.
Wunderink L, Nieboer RM, Wiersma D, Sytema S, Nienhuis. Recovery in remitted first-episode psychosis at 7 years of follow-up of an early dose reduction/discontinuation or maintenance treatment strategy: long-term follow-up of a 2-year randomized clinical trial. JAMA Psychiatry 2013;70: 913–920.
16.
17.
18.
Kennedy HG, O’Neill C, Flynn G, Gill P, Davoren M. The Dundrum toolkit. Dangerousness, understanding, recovery and urgency manual (the DUNDRUM quartet) V1.0.30 (30/05/16). Four structured professional judgment instruments for admission triage, urgency, treatment completion and recovery assessments. Trinity College Dublin: Dublin, Ireland; 2010.
19.
Prochaska JO, DiClemente CC. Stages and processes of self-change of smoking: towards an integrative model of change. J Consult Clin Psychol. 1983;51:350–95.CrossRef
20.
21.
22.
Davoren M, O'Dwyer S, Abidin Z, Naughton L, Gibbons O, Doyle E, McDonnell K, Monks S, Kennedy HG. Prospective in-patient cohort study of moves between levels of therapeutic security: the DUNDRUM-1 triage security, DUNDRUM-3 programme completion and DUNDRUM-4 recovery scales and the HCR-20. BMC Psychiatry. 2012;12:80.CrossRefPubMedPubMedCentral
23.
Davoren M, Abidin Z, Naughton L, Gibbons O, Nulty A, Wright B, Kennedy HG. 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. BMC Psychiatry. 2013;13:185.CrossRefPubMedPubMedCentral
24.
Shinkfield G, Ogloff J. A review and analysis of routine outcome measures for forensic mental health services. International Journal of Forensic Mental Health. 2014;13:252–71.CrossRef
25.
Webster C. Simon Fraser University. Mental health, L., policy, I., forensic psychiatric Services Commission of British, C., HCR-20 : assessing risk for violence. Mental health, law, and policy institute, Simon Fraser University. In: cooperation with the British Columbia forensic psychiatric services commission; 1997.
26.
Campbell MA, French S, Gendreau P. The prediction of violence in adult offenders. Crim Justice Behav. 2009;36:567–90.CrossRef
27.
Yang M, Wong SCP, Coid J. The efficacy of violence prediction: a meta-analytic comparison of nine risk assessment tools. Psychol Bull. 2010;136:740–67.CrossRefPubMed
28.
Olsson H, Strand S, Kristiansen L, Sjöling M, Asplund K. 2013. Decreased risk for violence in patients admitted to forensic care, measured with the HCR-20. Arch Psychiatr Nurs. 2013;27:191–7.CrossRefPubMed
29.
30.
O'Shea LE, Dickens GL. The HCR-20 as a measure of reliable and clinically significant change in violence risk among secure psychiatric inpatients. Compr Psychiatry. 2015;62:132–40.CrossRefPubMed
31.
32.
33.
Edwards J, Steed P, Murray K. Clinical and forensic outcome 2 years and 5 years after admission to a medium secure unit. The Journal of Forensic Psychiatry. 2002;13:68–87.CrossRef
34.
O'Neill C, Heffernan P, Goggins R, Corcoran C, Linehan S, Duffy D, O'Neill H, Smith C, Kennedy HG. Long-stay forensic psychiatric inpatients in the Republic of Ireland: aggregated needs assessment. Ir J Psychol Med. 2003;20:119–25.CrossRef
35.
Rutherford M, Duggan S. Forensic mental health services: facts and figures on current provision. Br J Forensic Pract. 2008;10, 10(4)
36.
Shah A, Waldron G, Boast N, Coid JW, Ullrich S. Factors associated with length of admission at a medium secure forensic psychiatric unit. J Forensic Psychiatry Psychol. 2011;22:496–512.CrossRef
37.
Sharma A, Dunn W, O’Toole C, Kennedy HG. The virtual institution: cross-sectional length of stay in general adult and forensic psychiatry beds. Int J Ment Heal Syst. 2015;9:25.CrossRef
38.
39.
Chang WC, Hui CLM, Wong GHY, Chan SKW, Lee EHM, Chen EYH. 2013. Symptomatic remission and cognitive impairment in first-episode schizophrenia: a prospective 3-year follow-up study. The Journal of Clinical Psychiatry. 2013;74:e1046–53.CrossRefPubMed
40.
Kahn RS, Keefe RSE. 2013. Schizophrenia is a cognitive illness time for a change in focus. JAMA Psychiatry. 2013;70:1107–12.CrossRefPubMed
41.
42.
Jorm AF. Is depression a risk factor for dementia or cognitive decline? Gerontology. 2000;46:219–27.CrossRefPubMed
43.
Stahlberg O, Soderstrom H, Rastam M, Gillberg C. Bipolar disorder, schizophrenia, and other psychotic disorders in adults with childhood onset AD/HD and/or autism spectrum disorders. J Neural Transm. 2004;111:891–902.CrossRefPubMed
44.
O’Reilly K, Donohoe G, Coyle C, O’Sullivan D, Rowe A, Losty M, McDonagh T, McGuinness L, Ennis Y, Watts E, Brennan L, Owens E, Davoren M, Mullaney R, Abidin Z, Kennedy HG. Prospective cohort study of the relationship between neuro-cognition, social cognition and violence in forensic patients with schizophrenia and schizoaffective disorder. BMC Psychiatry. 2015;15:155.CrossRefPubMedPubMedCentral
45.
Andreasson H, Nyman M, Krona H, Meyer L, Anckarsäter H, Nilsson T, Hofvander B. Predictors of length of stay in forensic psychiatry: the influence of perceived risk of violence. Int J Law Psychiatry. 2014;37:635–42.CrossRefPubMed
46.
Hasson-Ohayon I, Goldzweig G, Lavi-Rotenberg A, Luther L, Lysaker PH. The centrality of cognitive symptoms and metacognition within the interacting network of symptoms, neurocognition, social cognition and metacognition in schizophrenia. Schizophr Res 2018 Jul 9. pii: S0920–9964(18)30422–5. doi: https://​doi.​org/​10.​1016/​j.​schres.​2018.​07.​007
47.
48.
Flynn G, O'Neill C, McInerney C, Kennedy HG. The DUNDRUM-1 structured professional judgment for triage to appropriate levels of therapeutic security: retrospective-cohort validation study. BMC Psychiatry. 2011;11:43.CrossRefPubMedPubMedCentral
49.
Flynn G, O'Neill C, Kennedy HG. DUNDRUM-2: prospective validation of a structured professional judgment instrument assessing priority for admission from the waiting list for a forensic mental health hospital. BMC Research Notes. 2011;4:230.CrossRefPubMedPubMedCentral
50.
Pillay SM, Oliver B, Butler L, Kennedy HG. Risk stratification and the care pathway. Ir J Psychol Med. 2008;25:123–7.CrossRef
51.
Abidin Z, Davoren M, Naughton L, Gibbons O, Nulty A, Kennedy HG. Susceptibility (risk and protective) factors for in-patient violence and self-harm: prospective study of structured professional judgement instruments START and SAPROF, DUNDRUM-3 and DUNDRUM-4 in forensic mental health services. BMC Psychiatry. 2013;13:197.CrossRefPubMedPubMedCentral
52.
First MB, Spitzer RL, Gibbon M, Williams JB. Structured clinical interview for DSM-IV-TR axis I disorders, research version, patient edition. SCID-I/P. 2002;
53.
Nuechterlein KH, Green MF, Kern RS, Baade LE, Barch DM, Cohen JD, Essock S, Fenton WS, Frese FJ, Gold JM, Goldberg T, Heaton RK, Keefe RSE, Kraemer H, Mesholam-Gately R, Seidman LJ, Stover E, Weinberger DR, Young AS, Zalcman S, Marder SR. The MATRICS consensus cognitive battery, part 1: test selection, reliability, and validity. Am J Psychiatr. 2008;165:203–13.CrossRefPubMed
54.
Keefe RSE, Fox KH, Harvey PD, Cucchiaro J, Siu C, Loebel A. 2011. Characteristics of the MATRICS consensus cognitive battery in a 29-site antipsychotic schizophrenia clinical trial. Schizophr Res. 2011;125:161–8.CrossRefPubMed
55.
Kay SR, Flszbein A, Opfer LA. The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophr Bull. 1987;13:261.CrossRefPubMed
56.
O'Dwyer S, Davoren M, Abidin Z, Doyle E, McDonnell K, Kennedy HG. The DUNDRUM quartet: validation of structured professional judgement instruments DUNDRUM-3 assessment of programme completion and DUNDRUM-4 assessment of recovery in forensic mental health services. BMC Research Notes. 2011;4:229.CrossRefPubMedPubMedCentral
57.
58.
Mental Health Act 2001 (Approved Centres) Regulations 2006. S.I. No. 551 of 2006, The Stationery Office, Dublin.
59.
Mental Health Commission. Quality Framework. Mental health Services in Ireland 2007. MHC. In: Dublin; 2007.
60.
Mental Health Commission. Judgement Support Framework V5. MHC, Dublin. Feb 2018:2018.
61.
American Psychiatric Association 2004. Practice guidance for the treatment of patients with schizophrenia 2nd edition 2004 & 2010. APA, Washington 2010.
62.
Taylor D, Paton C, Kapur S. 2009. The Maudsley prescribing guidelines 10th edition. Informa Healthcare, London 2009.
63.
Copeland ME. Wellness recovery action plan (WRAP). Human Potential Pess: Advocates for Human Potential Inc; 2015. ISBN 978-09795560-9-8
64.
Naughton M, Nulty A, Abidin Z, Davoren M, O'Dwyer S, Kennedy HG. Effects of group meta-cognitive training (MCT) on mental capacity and functioning in patients with psychosis in a secure forensic psychiatric hospital: a prospective-cohort waiting list controlled study. BMC Research Notes. 2012;5:302.CrossRefPubMedPubMedCentral
65.
Anderson. B. Scott. S. 2001. Get sorted with drugs and alcohol: a resource pack for working with drug and alcohol users. Pavillion Publishing, Brighton.
66.
Coyle, C., O’Reilly, K. Kennedy, H.G. 2015. Acute Cluster Substance Use Psychoeducation Group Manual: Intervention and Procedures. National Forensic Mental Health Service, Dublin.
67.
Stocks. R. 2004 Saying no to drugs and Alcohol The State Hospital, Carstairs, 2004.
68.
Nulty A, McGuire J, Kennedy HG, Timmons D, Braham P, Cunningham A, Dunmurray A, McGrath C, Newe E, Nolan M, Tuohy M. Self-risk management group programme for forensic mental health. National Forensic Mental Health Service, Dundrum, Dublin. Theatr Irel.
69.
Nulty A, McGuire J. Self-risk management: therapist resource for individual sessions. National Forensic Mental Health Service, Dundrum, Dublin. Theatr Irel.
70.
Kielhofner G. 2002. A Model of Human Occupation: Theory and Application. Wolters Kluwer Health, Lippincott, Williams and Wilkins, Baltimore MD.
71.
Royal College of Psychiatrists (2014). Standards for Medium Secure Services: Quality Network for Forensic Mental Health Services. CCQI 178. London, England, UK.
72.
73.
74.
Hoaglin DC, Iglewicz B. Fine-Tuning Some Resistant Rules for Outlier Labeling. J Am Stat Assoc. 1987;82:1147–9.CrossRef
75.
Morris SB, DeShon RP. Combining effect size estimates in meta-analysis with repeated measures and independent-groups designs. Psychol Methods. 2002;7:105–25.CrossRefPubMed
76.
Evans C, Margison F, Barkham M. The contribution of reliable and clinically significant change methods to evidence-based mental health. Evidence Based Mental Health. 1998;1:70.CrossRef
77.
Hayes AF. Introduction to mediation, moderation, and conditional process analysis: a regression-based approach: Guilford Press; 2013.
78.
Livingston JD, Nijdam-Jones A, Lapsley S, Calderwood C, Brink J. Supporting recovery by improving patient engagement in a forensic mental health hospital: results from a demonstration project. Journal of the American Psychiatric Nurses Association. 2013;19:132–45.CrossRefPubMed
79.
Kersten L, Cislo AM, Lynch M, Shea K, Trestman RL. Evaluating START NOW: a skills-based psychotherapy for inmates of correctional systems. Psychiatr Serv. 2015;67:37–42.CrossRefPubMed
80.
Cislo AM, Trestman RL. Psychiatric hospitalization after participation in START NOW. Pschiatric Services. 2016;67:143.CrossRef
81.
82.
Cullen AE, Clarke AY, Kuipers E, Hodgins S, Dean K, Fahy T. A multi-site randomized controlled trial of a cognitive skills programme for male mentally disordered offenders: social–cognitive outcomes. Psychol Med. 2012;42:557–69.CrossRefPubMed
83.
84.
85.
86.
Young S, Das M, Gudjonsson GH, 2016. Reasoning and Rehabilitation cognitive skills programme for mentally disordered offenders: Predictors of outcome. World J Psychiatry 2016;6: 410–418.
87.
Lehman AF, Lieberman JA, Dixon LB, McGlashan TH, Miller AL, Perkins DO, Kreyenbuhl J, McIntyre JS, Charles SC, Altshuler K. Practice guideline for the treatment of patients with schizophrenia. Am J Psychiatr 2004;161(2 SUPPL.).
88.
89.
Miller SD, Hubble MA, Chow D, Seidel J. Beyond measures and monitoring: realizing the potential of feedback-informed treatment. Psychotherapy. 2015;52:449–57.CrossRefPubMed
Metadata
Title
Prospective observational cohort study of ‘treatment as usual’ over four years for patients with schizophrenia in a national forensic hospital
Authors
Melanie S. Richter
Ken O’Reilly
Danny O’Sullivan
Padraic O’Flynn
Aiden Corvin
Gary Donohoe
Ciaran Coyle
Mary Davoren
Caroline Higgins
Orla Byrne
Tina Nutley
Andrea Nulty
Kapil Sharma
Paul O’Connell
Harry G. Kennedy
Publication date
01-12-2018
Publisher
BioMed Central
Published in
BMC Psychiatry / Issue 1/2018
Electronic ISSN: 1471-244X
DOI
https://doi.org/10.1186/s12888-018-1862-0

Other articles of this Issue 1/2018

BMC Psychiatry 1/2018 Go to the issue

Research article

‘Suicide rates in Crete, Greece during the economic crisis: the effect of age, gender, unemployment and mental health service provision’

Research article

Risk behavior in patients with severe mental disorders: a prospective study of 121,830 patients managed in rural households of western China

Research article

The impact of child maltreatment on non-suicidal self-injury: data from a representative sample of the general population

Study protocol

Effectiveness of smartphone-based ambulatory assessment (SBAA-BD) including a predicting system for upcoming episodes in the long-term treatment of patients with bipolar disorders: study protocol for a randomized controlled single-blind trial

Research article

Association between depression and the risk for fracture: a meta-analysis and systematic review

Correction

Correction to: Reasons for lithium discontinuation in men and women with bipolar disorder: a retrospective cohort study