Social Correlates in

Forensic Mental Health

Dr. Carrick Anderson Psychiatric Registrar

Dr. Fiona Black Clinical Psychologist

Social Determinants of Health Conference – Sydney – December 2013

Outline Health

Mental health

Forensic mental health

Forensic mental health in Queensland

Queensland’s forensic psychiatric hospital

Case example

Treating illness and managing risk

Treatment vs intervention vs prevention

Future directions

Health / Mental Health

“A state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community”.

World Health Organization December 2013

AH&MRC definition of health: “not just the physical wellbeing of an individual, but refers to the social, emotional, and cultural wellbeing of the whole Community in which each individual is able to achieve their full potential as a human being, thereby bringing about the total wellbeing of their Community. It is a whole of life view and includes the cyclical concept of life-death-life”.

National Aboriginal Health Strategy 1989

Mental Health The 2007 National Survey of Mental Health and Wellbeing

estimates that almost half of Australians aged 16-85

experienced a mental disorder over their lifetime.

Each year 1 in 5 Australians in this age range are estimated

to experience symptoms of a mental disorder

The Australian Bureau of Statistics causes of deaths 2011 –

6 suicides per day. This may be underreported. Men are four

times more likely to die by suicide than women. Australian

Indigenous people are 2.5 to 3 times more likely to die by

suicide than others. There are 180 suicide attempts per day.

Mental Health Global burden of disease attributable to mental and substance

abuse disorders: findings from the Global Burden of Disease Study 2010 published in Lancet 2013.

Premature mortality as Years of Life Lost (YLL) from cause of death estimates for 1980-2010 from 187 countries was calculated. Years Lived with Disability was calculated. Disability-adjusted life years (DALYs) were derived from the sum of YLDs and YLLs.

Findings were mental and substance use disorders accounted for 7.4% of all DALYs worldwide. They were the leading cause of YLDs worldwide. Depressive disorders accounted for 40%, anxiety disorders 15%, combined drug and alcohol use disorders 20%, and schizophrenia for 7%. The highest proportion of DALYs occurred in people aged between 10 and 29 years.

In view of the magnitude of their contribution, improvement in population health is only possible if countries make the prevention and treatment of mental and substance use disorders a priority.

Mental Health Estimating treatment rates for mental disorders in Australia

Untreated mental disorders incur major economic costs and

personal suffering.

The percentage of Australians with a mental disorder who

received treatment for that disorder each year between 2006-

07 and 2009-10

The estimated treatment rate increased from 37% to 46% oer

that time – this was attributed to the introduction of the Better

Access programme.

Mental Health (continued) Lots of factors mentioned in relation to physical health that are

exacerbated in and complicated by mental illness

Distance (statewide services)

Income (public vs private)

Education (onset of mental illness)

Indigenous disparity

Accommodation and homelessness

Unemployment

Loss of hope/fear of failure

Smoking

Other substance use

Obesity

Jurisdictional division

Transport

Communication/language/health literacy

Gambling

Acquired Brain Injury

Religious/spiritual factors

Mental Illness

Social factors that contribute to development of mental illness

Early development critical

Vulnerability

Abuse and neglect

Social factors that perpetuate mental illness

Stigma, access to services

Social factors that contribute to recovery/rehabilitation

Housing

Famly, social, intimiate relationships

Best outcomes:

Least comorbidity

Early intervention

Good response to medication

Multidisciplinary work

Forensic Mental Health

Even further complicated by offending behaviour which in

itself is a multifactorial social problem.

Patients in forensic mental health often have complicated

comorbidities:

Mental illness

Personality disorder

Acquired brain injury / intellectual impairment

Substance use

Forensic Mental Health in

Queensland

Court Liaison Service (CLS)

Prison Mental Health

Service (PMHS)

High Security Inpatient

Service (HSIS)

Community Forensic

Mental Health Service

(CFOS)

Queensland’s Forensic Psychiatric

Hospital

Classified patients

Prisoners – serious violent offences

Hospitalised for assessment and treatment

Forensic patients

Found of unsound mind in relation to serious violent offence

Hospitalised for treatment rather than going through criminal

justice system

Gain leave through Mental Health Review Tribunals

Queensland’s Forensic Psychiatric

Hospital (continued) General passage through Queensland’s forensic psychiatric

hospital

Admission, stabilisation of mental illness

Addressing problematic behaviour

Engagement in psychotherapy, occupational therapy

Social work – family and community engagement

Community access, rehabilitation focus

Treating Illness and Managing Risk What are Patient A’s health needs?

What are Patient A’s forensic needs?

Forensic mental health – dual role

One and the same?

Social correlates of health equate with risk factors for violent

behaviour

HCR-20 (Webster, Douglas, Eaves & Hart, 1997)

H1 Previous Violence

H2 Young Age at First

Violent Incident

H3 Relationship Instability

H4 Employment Problems

H5 Substance Misuse

Problems

H6 Major Mental Illness

H7 Psychopathy

H8 Early Maladjustment

H9 Personality Disorder

H10 Prior Supervision

Failure

C1 Lack of Insight

C2 Negative Attitudes

C3 Active Symptoms of Major Mental Illness

C4 Impulsivity

C5 Unresponsive to Treatment

R1 Plans Lack Feasibility

R2 Exposure to Destabilisers

R3 Lack of Personal Support

R4 Non-compliance with Remediation Attempts

R5 Stress

Treatment / Intervention

(Prevention) For Patient A, a lot of his treatment needs are also the areas

that require intervention to ameliorate or manage risk

If we had had the opportunity, these would have been the

same areas for early intervention

Future Directions Clinicians to be aware of broader policies and drivers within

health – work to a common vision (nationally)

Increase profile of mental health

Holistic approach to health – physical, mental, social, spiritual

Importance of inter-agency relationships

Importance of research and evidence based practice

Early community action can prevent even high security hospitalisation

Contact details:

fiona.a.black@gmail.com carrick.anderson@yahoo.com