Forensic psychiatry

Question 1

what is forensic psychiatry

Answer 1

• interface between psychiatry and the law
• role of forensic psychiatrist:
  1. treat mentally disordered offenders - those who pose a serious risk of violence
  2. violence and risk assessment and management
• opinions for courts and other bodies
• opinions for other mental health services
  3. offer expert opinions to courts
• fitness to plead
• diminished responsibility
• NGRI

Question 2

assessment and treatment of mentally disordered offenders

Answer 2

1. pre-trial assessment
   - fitness to plead
   - criminal responsibility due to mental disorder
2. prison assessments
   - out patients in prison settings
3. community assessment
   - violence risk posed by community general adult patients / other patients

Question 3

mental health act 2001 admissions to the central mental hospital (CMH)

Answer 3

• civil, not criminal, act transfers
• exceed the capacity of their local service - assaults, seclusion
• process

Question 4

Criminal law (insanity act): fitness to plead

Answer 4

• a patient is unfit to plead if they cannot (due to mental health disorder)
  1. plead to the charges
  2. instruct a legal representative
  3. elect for trial by jury
  4. challenge a juror
  5. understand evidence
• can be directed to CMH by a judge for a 14 day assessment of fitness
• if found unfit need to remain in CMH until found fit and the case can then proceed

Question 5

Criminal Law (insanity act) 2006: concept of responsibility

Answer 5

• full responsibility - full rationality and consciousness at time of offence (at the material time)
• crime = actus reus (guilty act) + mens rea (guilty mind)
• test of capacity to form intent
• insanity = absence of mens rea (guilty mind)

Question 6

Criminal law (insanity) act 2006: not guilty by reason of insanity (NGRI)

Answer 6

(a) the accused person was suffering at the time from a mental disorder

AND

(b) the mental disorder was such that the accused person ought not to be held responsible for the act alleged by reason of the fact that he or she;
1) did not know the nature and quality of the act
OR
2) did not know what he or she was doing was wrong
OR
3) was unable to refrain from committing the act

Question 7

if found NGRI

Answer 7

1. no criminal record relating to the act
2. transferred to the central mental hospital for care and treatment
3. must remain in the CMH until he or she receives a conditional or unconditional discharge from the mental health review board
   - the purpose of the conditions are to:
4. support the patient to remain well and stable in their mental state
5. manage risk of violence and other risks
6. but may also need to accomodate victim rights etc
7. all will be individualized to the patient, agreed at the Mental health review board where the patient and their solicitor will be able to discuss with the panel

Question 8

Complexity of NGRI assessments, secondary gain, exaggerating symptoms

Answer 8

1. assessment of secondary gain and potential exaggeration of symptoms is a key issue for NGRI assessments
   - accuracy of assessment is in a patients interests. inaccurate diagnoses can lead to a polypharmacy and unnecessary treatments
2. typically on remand, charged with murder - highly stressful situation - therefore feigning or exaggerating symptoms and secondary gain are always consideration
   - complete assessment of book of evidence is core to these assessments as well as several interviews and assessments
3. the ability to accurately assess mental state in relation to NGRI court disposals) is a vital skill for all consultant forensic psychiatrist. it is core to this discipline of medicine

Question 9

outcomes after NGRI - supervisability in the community setting

Answer 9

conditions to discharge to the community that will almost always be included;
1. must stay on your medication
2. must remain abstinent from drugs/ novel psychoactive substances
3. must come to consultant reviews
4. must remain violence free

Question 10

Approaches to risk management

Answer 10

1. know history
2. complete a HCR-20 - realistically - be aware of issues around minimizing
   - is the patient still in the mental state where serious violence took place?
3. treatment and intervention
   - treat the psychosis - be aware of the issues around insight and the need for depot medications, accepting meds as in patient vs out patient
4. substance misuse
5. use of graded programme leave
6. Victim sensitivity and public confidence - previous victims, exclusion zones, media interest