Psychological and psychosocial interventions in forensic psychiatric care

A systematic review and assessment of medical, economic, social and ethical aspects

SBU Assessment

Presents a comprehensive, systematic assessment of available scientific evidence for effects on health, social welfare or disability. Full assessments include economic, social and ethical impact analyses. Assessment teams include professional practitioners and academics. Before publication the report is reviewed by external experts, and scientific conclusions approved by the SBU Board of Directors.

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Aim

The conditions for psychological and psychosocial interventions within forensic psychiatric care differ in many ways from non-compulsory psychiatry. This project focuses on the benefits and risks of interventions used in forensic psychiatry, including their health economic and ethical aspects, and the experiences of patients who have been remitted to forensic psychiatric care. The assignment to evaluate interventions in forensic psychiatric care came from The Ministry of Health and Social Affairs. An earlier mapping of systematic reviews pertaining to interventions used in forensic psychiatry (SBU 2017) indicate a substantial need for well conducted research.

Conclusions

  • The effects of psychological and psychosocial interventions used in forensic psychiatric settings need to be explored. Only a few studies of psychological interventions that had been adjusted for forensic psychiatric settings were identified. The studies were heterogenous, ex­amining various interventions and providing different outcomes. There is insufficient data to draw any conclusions about the effects of the interventions. No studies on psychosocial interventions were identified. Many of the interventions currently being used in forensic psychiatry were developed for other care settings, but their usability and efficacity may be influenced by the fact that, in contrast to treat­ment in open psychiatry, forensic psychiatric care is compulsory and that patients treated in forensic psychiatric care are more likely to have multiple concurrent diagnoses.
  • The costs associated with psychological interven­tions are very low compared to the total cost of care. Therefore, interventions which shorten the time spent in forensic psychiatric care would very likely be cost effective.
  • Obtaining more understanding is urgent from an ethical point of view. Forensic psychiatric care is an extensive and often prolonged encroachment on an individual’s life and autonomy. That we do not know if the treatments being provided are effective creates a particularly problematic ethical dilemma.
  • Increased coordination of research in this field could provide more reliable information by permitting larger studies with more homogen­eous interventions and outcomes to be conducted. In the last few years, some studies have been conducted on interventions adapted for patients in forensic psychiatric settings.
  • There is a need for research that can support the development of healthcare in forensic psychiatric care. Interview studies from Swedish foren­sic psychiatric care settings indicate that patients often feel exposed and vulnerable.
  • The goals defined in healthcare legislation about care on equal terms points to the need for a more uniform forensic psychiatric care. Interventions must be based on a scientific evidence.
  • Forensic psychiatric care varies considerably throughout Sweden. An inventory of current practices shows that clinics differ substantially in which interventions they provide. Many of the interventions were locally developed and lack scientific ground and systematic follow-up. The ability to offer alternative treatments also varies.

What are the implications?

These results demonstrate that there is a large need for research that can support the development of psychological and psychosocial interventions, as well as general healthcare and nursing, and help to improve how patients are met in forensic psychiatric care. The results also indicate that the way forensic psychiatry is conducted varies throughout Sweden.

Background

Severe psychiatric illness is a legal term rather than a medical term. In Sweden, a person who commits a crime when they have an active severe psychi­atric illness can be sentenced to receive forensic psychi­atric care rather than incarceration. Approximately 300 individuals are remitted to forensic psychiatric care each year.

Forensic psychiatric care is regulated in part by the same laws that regulate all Swedish healthcare and in part by penal laws. Patients remitted to forensic psychiatric care have diverse diagnoses and the most common diagnosis is psychosis. Autism and personality disorders are also common. These patients often have a substantial need for healthcare. The care provided by forensic psychiatry resembles the care provided by other psychiatric care providers, often using the same treatments.

Method

The project was conducted in accordance to the methods of SBU. This assessment consists of three systematic reviews. The first assessed the effects of psychological treatments and psychosocial interventions examined in controlled studies that were conducted in forensic psychiatric settings and considered transferable to the Swedish system. The second assessed the qualitative evidence regarding the experiences of patients remitted to forensic psychiatric care in Sweden. The third was a systematic review of health economic assessments; this was complemented with cost information associated with interventions, the over-all care and the legal process in the Swedish system. The systematic reviews were complemented with a survey of current clinical practices used in Swedish forensic psychiatric care and an ethical evaluation.

Main results

Five studies of effects of treatment met the inclusion criteria for the systematic review on psychological treatments and psychosocial interventions. All were cognitive behavioral therapies that had been adapted for use in forensic psychiatric settings. The studies were too heterogenous in treatment and outcome to allow meta-analysis. No studies on psychosocial interventions were identified.

Four qualitative studies on patient experiences from Swedish forensic psychiatry were identified. The studies suggest that these patients often feel vulnerable, that they lack autonomy and adequate influence over their care.

No economic evaluations which meet the inclusion criteria for the project were identified. The systematic review was complemented with an assessment of the related costs in Sweden that showed that the costs of interventions are very low in relation to the total cost of forensic psychiatric care.

Discussion

Our assessment of psychological treatments and psychosocial interventions clearly indicates a lack of research in forensic psychiatric care; there are few effect studies in the field. It is promising that more interventions have been adapted for this population in the last few years, and that research into their efficacity has begun.

It should be noted that the lack of research does not imply that an intervention lacks effect, but rather that its effect has not been sufficiently researched.

Other aspects of care and how patients are treated in forensic psychiatry are also important for patient recovery. Initiatives to develop this work should be encouraged. Psychological treatments, psychosocial interventions, and general healthcare together with pharmacological treatment are all important elements of forensic psychiatric care; they depend on each other to achieve the best results.

The full report in Swedish

The full report in Swedish Psykologiska behandlingar och psykosociala insatser i rättspsykiatrisk vård 

Published: Report no: 287 https://www.sbu.se/287e

Project group

Experts

  • Malin Lotterberg (literature review, analysis and report)
  • Björn Hofvander (literature review, analysis and report)
  • Ulf Axberg (analysis and report)
  • Susanna Radovic (ethics)

SBU

  • Alexandra Snellman (Project Manager)
  • Mikael Nilsson (Assistant Project Manager)
  • Nathalie Peira (Assistant Project Manager)
  • Emin Hoxha Ekström (Health Economist)
  • Kickan Håkanson (Project Administrator)

Flow charts

From start 8174 abstracts. 12 were relevant, 5 medium high risk for bias, 7 high risk for bias

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