Crimes and sentences in individuals with intellectual disability in a forensic psychiatric context: a register-based study

Aims To study associations between intellectual disability (ID) and sexual and violent offending among individuals subject to pre-trial forensic psychiatric assessment. To investigate sentences following pre-trial forensic psychiatric assessment in offenders with and without ID. Methods A population-based observational study using data from pre-trial forensic psychiatric assessments in Sweden (1997–2013), the Swedish National Crime Register and several other Swedish national registers. The study population consisted of 7450 offenders (87% men, 13% women) who were subject to forensic psychiatric assessment in 1997–2013, of whom 481 (6.5%) were clinically assessed as having ID. Results ID offenders were more likely than non-ID offenders to have a sexual crime as an index crime [26.2 v. 11.5%, adjusted odds ratio (OR) 2.7, 95% confidence interval (CI) 2.02–3.58] as well as previous convictions regarding sexual offending (10.4 v. 5.6%, adj OR 2.3, 95% CI 1.70–3.12). These associations were restricted to male offenders; sexual offending was uncommon among women. Comorbid attention-deficit hyperactivity disorder reduced the association between ID and sexual offending (adj OR 2.7 v. 3.1, p = 0.017), while comorbid autism spectrum disorder had no significant influence on the association (adj OR 2.7 v. 3.0, p = 0.059). Violent crime was equally common among ID and non-ID offenders. Offenders with ID were more likely than non-ID offenders to be sentenced to forensic psychiatric care or community sanctions and measures (such as probation, conditional sentences or fines) than to prison; however, 15% of individuals who received an ID diagnosis during the forensic psychiatric assessment were sentenced to prison. Previous criminal convictions, concurrent antisocial personality disorders and substance use disorders were associated with a higher probability of a prison sentence among offenders with ID. Conclusions Sexual crime is overrepresented among offenders with ID compared to offenders with other mental disorders than ID in forensic psychiatric contexts. ID offenders become subject to forensic psychiatric care and forensic psychiatric services need evidence-based treatment programmes for offenders with ID. In addition, there is a need for early intervention strategies suitable for disability services and special education schools, in order to address the complex needs of individuals with ID and prevent sexual and violent offending.

The Goldwater Rule: a bastion of a bygone era?

In tandem with the changing political landscape in recent years, interest in the Goldwater Rule has re-emerged within psychiatric discourse. Initiated in 1973, the Goldwater Rule is an ethical code specific to psychiatry created by the American Psychiatric Association in response to events surrounding the USA presidential election of 1964, in which the integrity of the psychiatric profession was challenged. Current detractors view the rule as an antiquated entity which obfuscates psychiatric pragmatism and progression. Proponents underscore its role in maintaining both respectful objectivity and diagnostic integrity within the psychiatric assessment process. This essay aims to explore the origin of the rule, and critique its applicability to modern-day psychiatric practice.

Problematic issues of appealing against the decision of the investigating judge, the court on sending a person to a medical institution for a psychiatric assessment

The article reveals the problem of appealing against the decision of the investigating judge, the court on sending a person to a medical institution for a psychiatric assessment, in particular: a) it is stated that sending a person to a medical institution for assessment is a form of restriction of his or her constitutional right to liberty, which is equivalent to detention. It is proposed to amend the Criminal Procedure Code (hereinafter – the CPC), which provides for the right to a separate appeal against a court decision on sending a person to a medical institution for assessment, decided in court before the court decision on the merits. The lack of possibility to appeal against such a court decision creates a potential danger of illegal restriction of a person’s constitutional right to liberty and security during their placement in a medical institution for the inpatient forensic psychiatric assessment (hereinafter – the IFPA), which violates the essence of the right to judicial protection; b) it is proved that the decision of the investigating judge, the court to send a person to a medical institution for the IFPA may limit not only the rights of the suspect, accused, but thus also affect the legitimate interests of others who do not have procedural status in criminal proceedings. It is determined the expediency of granting the right to appeal the said court decision to the victim and other persons whose interests it concerns; c) it is noted that the mechanism of prolongation of the term of the IFPA is not regulated in the domestic criminal procedural law, however judges continue it in the absence of a legislative basis. Therefore, it is expressed the scientific position on the rationality of appealing not only the decision of the investigating judge, but also the court’s decision to extend the term for sending a person to a medical institution for assessment.

Factors associated with increased suicidality risk following referral for isotretinoin commencement

Objective: To establish whether there is a significant change in suicidality risk following psychiatric assessment for commencement of isotretinoin and identify factors that underpin any potential risk change. Method: Retrospective cohort study. Suicidality risk was defined as a combination of the following: (i) actual/intended self-harm and/or attempted/completed suicide, and (ii) increased service utilisation associated with suicidal ideation/behaviour. All patients referred to Psychiatry for assessment prior to commencement of isotretinoin between 2014 and 2019 were examined. Inclusion criteria: >16 years of age, assessed for commencement of isotretinoin, complete clinical records. Data were collected by reviewing the Electronic Patient Records. Fifty-seven patients were eligible. We employed descriptive statistics, parametric/non-parametric/normality tests and logistic regression analysis, using socio-demographic and clinical characteristics as independent parameters, and suicidality risk as the dependent parameter. Results: Actual/intended self-harm/attempted suicide decreased significantly following assessment without significant change in service utilisation. Female gender, absence of protective factors and assessment by Consultation-Liaison Psychiatry were linked to increased suicidality risk, after controlling for age, ethnicity, recommendation for isotretinoin, and substance misuse. Conclusions: Psychiatric assessment is helpful before commencing isotretinoin. Female gender, and absence of ongoing psychopharmacological and/or psychological intervention and/or regular psychiatric follow-up predict increased suicidality risk among patients assessed for prescription of isotretinoin.