International Journal of Risk and Recovery

ORIGINAL ARTICLE Forensic in the largest secure ward in Portugal: characteristics of the population and psychopharmacolog- ical intervention

Teresa Carvalhão 1, Patrícia Jorge 2, Paula Batalim 1

1 Centro Hospitalar e Universitário de Coimbra, action (mens rea). Should a person’s ca- Coimbra, Portugal pacity to understand the consequences of 2 Centro Hospitalar do Médio Tejo, Tomar, Portugal his/her actions have been impaired or di- minished due to a , article Forensic psychiatry is defined as a specialty of 20 of the Portuguese Criminal Code would psychiatry in which clinical and scientific apply. knowledge is applied to the legal system, both with regard to civil and criminal . Nowa- In this article, the term “not criminally re- days, the largest security ward is in Coimbra, sponsible” (NCR) is used as follows: Not at the University Hospital. It comprises 111 criminally responsible due to a mental dis- patients: 91 males and 20 females. The aim of order: 1- A person is not criminally re- the security measures, according to the penal sponsible if, due to a mental disorder, code, is the protection of legal assets and psy- he/she is incapable at the time of commit- chosocial rehabilitation. In our sample, the most frequent diagnosis was ting the act of appreciating its unlawful- (37.8%); Moderate Intellectual Disability ness or of conforming his/her conduct in (23.4%) and Mild Intellectual Disability (14.4%) accordance with that appreciation; 2- A were the second and third most frequent diag- person may be declared not criminally noses. The criminal acts accounting for the responsible if due to a serious mental dis- most prevalent security measures fell under order (unintentional in nature and whose domestic violence (19.8%) first, followed by effects he/she cannot control, without be- attempted murder (16.2%), and theft (14.5%). ing thereby censurable) he/she had had, The elaboration of a therapeutic and rehabilita- at the time of committing the act, the ca- tion plan is essential, and its aim is to diminish pacity to appreciate its unlawfulness or to the person’s dangerousness. It is fundamental to think of the safety ward as a health produc- conform his/her conduct in accordance tion space and not as a place of mere disease with that appreciation sensibly diminished; management or “dangerous states”, thus trying 3- The agent’s proved incapacity to be to solve the patient’s problems. influenced by punishment may constitute a sign of the situation defined in the previous Key words number; 4- Criminal responsibility is not Intellectual developmental disorder, forensic care, excluded when the mental disorder has Schizophrenia, pharmacological treatment pathways been caused by the agent himself/herself with the intention to commit the act [2]. Introduction Once an individual is found not criminally Forensic psychiatry is defined as a spe- responsible, it entails that the mental ill- cialty of psychiatry in which clinical and ness was at the origin of the offense. The scientific knowledge is applied to the legal symptoms of their mental disorder are system, both with regard to civil and crimi- considered to be the cause of their behav- nal law [1]. One of the most interesting iour. Therefore, managing psychiatric issues in this relationship between law and symptoms would aid in mitigating risk. psychiatry is the problem of criminal re- Additionally, the probability of reoffending sponsibility [1], where it must be deter- is related to the severity of the mental dis- mined whether or not an individual was order and the likelihood of psychiatric re- aware of the consequences of his/her un- lapse, but involuntary admission is not lawful action before or at the time of the

Int J Risk Recov 2019;2(1):11-7 https://doi.org./10.15173/ijrr.v2i1.3501 Carvalhão et al. IJRR 2019;2(1)

necessarily justified simply with being initially decided by the court at the time of found to be NCR. Instead, security the NCR finding but can end at any time if measures appear to be justified when the court is satisfied that the level of dan- there is a high probability that the individu- gerousness that justified admission into al would relapse in a way that he/she the secure unit is no longer met. [3,4]. For would commit a similar unlawful action and serious crimes, where the sentence is would be found NCR for that act as well longer than 5 years in , the shortest [3]. possible duration of the security meas- ure(s) is 3 years. After the measure(s) Nowadays, the largest secure ward admit- has/have been implemented, a reassess- ting NCR patients in Portugal is in Coim- ment of the individual must take place eve- bra, at the University Hospital. In total, it ry two years. At any time, a judge can or- has 111 patients, 91 males and 20 fe- der a new assessment to evaluate the males. These patients were deemed not clinical and behavioural characteristics of criminally responsible on the account of a the patient [5,6]. mental disorder for the offense they com- mitted. The decision to admit them was This study aims to characterize the profiles made due to the level of risk they pose for of the patients found not criminally re- public safety; secure units are necessary sponsible and admitted in a secure Portu- due to their status as dangerous patients guese hospital as their characteristics with a high likelihood of reoffending in the complied with security measures criteria future [2]. as per the Portugal Criminal Code. The benefits and limitations of such medico- Once the NCR status is given to the ac- legal framework will be highlighted. cused, the issue of likelihood of reoffend- ing and therefore their level of dangerous- Materials and Methods ness becomes paramount. In accordance to the Portuguese Penal Code, the aim of A retrospective chart review was per- admitting dangerous NCR patients to a formed in the Forensic Psychiatry Program secure unit is to ensure public safety and in Coimbra, Portugal, between January their psychosocial rehabilitation, with the and March 2018. All patients admitted ultimate goal of safely reintroducing these during that period of time were deemed patients into the community. Placed safety eligible. Prior to receiving consent from all measure(s) must be proportionate to the patients to access their chart of the pur- seriousness of the index offense and to pose of conducting this study, the protocol the degree of dangerousness of the pa- was approved by our local Ethical Review tient (Article 40, paragraph 3 of the Penal Board. Digital and paper medical records Code [3]), and cannot, under the terms of of the inpatients were analysed. Their so- the Portuguese Constitution, be perpetual ciodemographic status, the types of crime or be of defined or indefinite duration. they committed, the duration of the securi- Likewise, the duration of the security ty measures, and the pharmacological measure(s) cannot exceed the duration of treatment they received were recorded. As the sentence for the crime committed (Ar- this is a descriptive study, no statistical ticle 30 of the Constitution of the Portu- analysis was performed. guese Republic). The security measure(s) may only be applied if the severity of the Results crime is proportional to the danger of the Sociodemographical data agent. The duration of the jail time as de- fined by the Portuguese Criminal Code The final sample included 111 subjects according to the committed offense will with an average age of 45.81 years old, indicate how long the patient who commit- ranging from 21 to 81 years old. Among ted a similar offense could be detained in our sample, 91% were younger than 65 the secure unit; however, the effective years old. The average age of female pa- time spent will depend on how long the tients was 46.19 years old (range 24 to patient remains a risk for public safety. 71). The average age of male patients was The duration of the security measure(s) is 45.52 years old (range 21 to 81). With

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respect to gender, there was a predomi- and intellectual disabilities account for nance of males (74.1%, n=83) compared 77.4% of diagnoses (Table 2). For fe- to females (24.1% n=27). males, the main diagnosis was mild intel- lectual disability (29.6%) and for males, it Index offense and legal outcome was schizophrenia (45.8%). The index offense that was associated Among our sample, 40% had a concur- most with the NCR finding and led to the rent disorder. Whereas concurrent disor- placement of the security measure(s) was der was found in 14.8% of the female domestic violence (19.8%), followed by population (n=4), it was found in 48.2% of attempted murder (16.2%) and theft the male population (n=40). (14.5%) (Table 1). Most of the patients committed only one crime at the time of Pharmacological data the index offense; 28.8% of the patients Oral antipsychotic drugs - Oral neurolep- had committed more than one crime for tics were prescribed for 90.1% of patients; which they were found NCR (n=32). 74.1% 51.4% (n=57) received first generation of the female population (n=27) and 30.1% antipsychotics and 71.2% (n=79) second of the male population (n=25) had commit- generation antipsychotics. It must be not- ted multiple offenses overall. ed that 66.7% (n=74) received neurolep- On average, the minimum sentence dura- tics from one of the generations as op- tion was 2.66 years. The average maxi- posed to 33.3% (n=37) from both genera- mum duration was 8.95 years. For women, tions. On average, the patients were med- the maximum penalty time was 6.52 years icated with 1.41 ± 0.9 different types of on average (ranging from 1 to 16 years), neuroleptics. The maximum number of while for men the average time was 9.78 antipsychotic medications prescribed per years (ranging from 1 to 25 years). patient was 5. Depot antipsychotic drugs - Depot anti- Table 1: Summary of the crimes psychotic formulations were used in 47.7% (n=53) of the sample. Haloperidol was the Offense Number of most commonly used, with 85% of patients patients (%) using it (73.4% took this on a monthly ba- Domestic violence 22 (19.8%) sis, with the rest taking it every 3 weeks). Attempted murder 18 (16.2%) The mean dose of haloperidol per month Theft 16 (14.5%) was 146 mg (ranging from 50 mg to 300 mg). Risperidone, a long-acting injection, Murder 11 (9.9%) was used in 9% of the patients (n=5) and Criminal offense 10 (9%) prescribed every 14 days. Paliperidone, a Forest fire 8 (7.2%) long-acting injection, was used in 5.7% of Possession/use weapon 6 (5.4%) the patients (n=3), with monthly injections. Qualified damage 4 (3.6%) Mood stabilizer drugs - Mood stabilizer Threat 4 (3.6%) drugs were prescribed in 36% of the cases Aggravated threat 4 (3.6%) (n=40). Among this group, 62.5% (n=25) Rape 4 (3.6%) were taking Valproic Acid with a mean Sexual coercion 1 (0.9%) dose of 1000 mg per day, 7.5% (n=3) To- Driving Without a Licence 1 (0.9%) piramate, 10% (n=4) Gabapentin, and 15% (n=6) Carbamazepine. Resistance to justice 1 (0.9%) Qualified kidnap 1 (0.9%) Benzodiazepines - Most patients (72.1%, n=80) were taking benzodiazepines. For Psychiatric conditions 10 patients (9%), two different types of benzodiazepines were prescribed. Re- The most frequent diagnoses were schiz- garding the type of benzodiazepines pre- ophrenia (37.8%), moderate intellectual scribed, Lorazepam was the most fre- disability (23.4%) and mild intellectual isa- quently used (55.6%) and Diazepam the bility (14.4%). Altogether, schizophrenia second most used (18.9%). Choices for

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types of benzodiazepines with long half- lives are highlighted. Other drugs - Only one patient had a psy- chostimulant treatment (0.9%), Methyl- phenidate. Three patients were on anti- dementia drugs (2.7%). Antidepressant therapy was used for 20 patients (18%).

Table 2: Main diagnoses based on DSM 5 criteria Notes: 1 – bipolar type; 2 - current or most recent episode manic, with psychotic features; 3 - persecutory type; 4 – severe; 5 – other (or unknown), severe; 6 - Intellectual Developmental Disorder.

Main diagnosis by DSM – 5 DSM-5 code Total of patients Male Female Frontotemporal Disease 294.11 2 (1,8%) 2 (2,4%) - Schizoaffective Disorder1 295.70 4 (3,6%) 1 (1,2%) 3 (11,1%) Schizophrenia 295.90 42 (38,2%) 38 (45,8%) 4 (14,8%) Bipolar Disorder2 296.44 2 (1,8%) 1 (1,2%) 1 (3,7%) Delusional Disorder3 297.1 10 (9,1%) 6 (7,2%) 4 (14,8%) Antisocial 301.7 3 (2,7%) 2 (2,4%) 1 (3,7%) Alcohol Use Disorder4 303.90 3 (2,7%) 3 (3,6%) - Substance Use Disorder5 304.90 1 (0,9%) - 1 (3,7%) Intellectual Disability, Mild6 317 16 (14,5%) 8 (9,6%) 8 (29,6%) Intellectual Disability, Moderate6 318.0 25 (22,7%) 20 (24,1%) 5 (18,5%) Intellectual Disability, Severe6 318.1 2 (1,8%) 2 (2,4%) -

Table 3: Summary of drugs used in the sample

Drugs Number of Male patients Female patients (%) (%) patients (%) Oral Antipsychotics First generation 57 (51.4) 48 (57.8) 9 (33.3) Second generation 79 (71.2) 64 (77.1) 15 (65.2) Depot Antipsychotics Haloperidol 45 (40.9) 38 (45.8) 7 (25.9) Risperidone 5 (4.5) 4 (4.8) 1 (3.7) Paliperidone 3 (2.7) 3 (3.6) - Mood stabilizers None 71 (64) Carbamazepine 6 (5.4) 4 (4.8) 2 (7.4) Gabapentin 4 (3.6) 3 (3.6) 1 (3.7) Lithium 2 (1.8) 1 (1.2) 1 (3.7) Topiramate 3 (2.7) 1 (1.2) 2 (7.4) Valproic acid 25 (22.5) 19 (22.9) 6 (22.2) Benzodiazepines Alprazolam 1 (1.1) 1 (1.2) - Clonazepam 10 (11.1) 7 (8.4) 3 (11.1) Diazepam 17 (18.9) 11 (13.3) 6 (22.2) Flurazepam 1 (1.1) 1 (1.2) - Lorazepam 50 (55.6) 42 (50.6) 8 (29.6) Oxazepam 11 (12.2) 9 (10.4) 2 (7.4)

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Discussion This descriptive study is a snapshot of the makes the use of various antipsychotics individuals admitted to the largest forensic for clinical stabilization necessary. Less program in Portugal and their pharmaco- than half of the patients were medicated logical treatment. with long-acting antipsychotic medications, in spite of its well-known advantages in From the obtained data, we can infer that patients with low adherence to therapy. most inpatients in the security ward are Poor adherence to treatment does not only young men. The main offense committed impact the clinical prognosis due to fre- was domestic violence. However, there quent relapses, it also directly and indirect- are differences when looking at patient ly increases health-related costs for the gender; in the female population, the most community [8]. Depot medication helps frequent offense is attempted murder decrease the number of the re- whereas in the male population, after do- hospitalizations, better helps long-term mestic violence, the most two frequent are stabilization of psychiatric symptoms, and kidnapping and murder. The co- helps promote follow-up for individuals occurrence of two psychiatric conditions is lacking insight into their mental illness [9]. frequent in our population; the most popu- Increasing the use of long-acting injectable lar one is the consumption of psychoactive drugs in the future may contribute to a substances, which is commonly found in better prognosis of patients with psychiat- offenders suffering from a ric diseases. condition [7]. In our sample, we found a prevalence of 40.5%, with a higher fre- Different medical algorithms suggest that quency in men. Schizophrenia and intel- the first therapeutic option should be sec- lectual disabilities are the most common ond-generation antipsychotics [10,11]. diagnoses, and altogether they represent First-generation antipsychotics are gener- 77.4% of the population. The presence of ally associated with extrapyramidal side intellectual disability is much more fre- effects, with increased hyperprolactinemia quent in men. Interestingly however, there and, in the long term, tardive dyskinesia are as many women diagnosed with intel- compared to second-generation antipsy- lectual disabilities as with a psychotic dis- chotics. Another aspect to take into ac- order, but there are double the amount of count is its therapeutic efficacy. Although men diagnosed with a psychotic disorder the results are not replicated in all studies, compared to those with intellectual disa- there are those who suggest that first- bilities. Taking into consideration the im- generation antipsychotics may be less pact of the intellectual disability in relation effective than second-generation antipsy- to violent behaviour is relevant when con- chotics clozapine, amisulpride, olanzapine, sidering treatment options and appropriate and risperidone [12]. Besides patients that placement in the community. Additionally, require a mood stabilizer due to the nature considering the severity of the mental ill- of their mental illness (bipolar disorder…), ness(es) is important in ensuring stability; the choice of this therapeutic class helps indeed, someone can offend due to an some patients control their impulses. An- acute psychotic episode/relapse, an unfor- other frequently prescribed psychophar- tunate and unexpected event, and others macological class was benzodiazepines. can offend due to recurrent and hard-to- These allow for control of anxiety through- treat associated with antisocial out the day as well as sleep regularization. and aggressive traits. The most commonly used benzodiaze- pines were those with long half-lives, al- As for the , most pa- lowing a greater stabilization of anxiogenic tients are under therapy with antipsychot- levels throughout the day. Future studies ics, either in oral forms or in long-term should look at the efficacy in risk man- injectable releases. The fact that we work agement depending on the type of anti- with a population with particular character- psychotic used, as most of the patients istics (serious behavioural changes, re- suffer from a psychotic disorder; research sistant psychosis situations) very often about concomitant use of another class of

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psychiatric drug would also be meaningful ordered by the Court; these patients can- to optimize pharmacological treatment and not refuse to be medically treated. focus on intervention. Conclusions Involuntary treatment within our population needs to be addressed. Indeed, lacking Therapeutic interventions in a secure pro- insight into their mental illness is often the gram dealing with NCR patients are based main barrier to initiate pharmacological on clinical-forensic and social parameters intervention. The peculiarity of Portuguese [5]. The aim of the security measures, in legislation is that involuntary treatment can accordance with the Portuguese Penal be initiated under an involuntary admission Code, is to protect the public and the psy- status without any other legal requirement. chosocial rehabilitation of the patients. The law established in 1998 in the Portu- This paper allows us to better understand guese Mental Health Law addressed both the outset of the largest forensic psychia- issues involuntary treatment and involun- try program in Portugal by looking at a tary admission [13]. Article 12 of the Por- sample of patients found not criminally tuguese Mental Health Law states that 1. responsible and admitted into a secure Anyone carrying an acute psychiatric unit in Portugal complying with security anomaly that by its nature creates a situa- measures, and it looks at sociodemo- tion of danger of significant value, to graphic aspects, crimes and duration of themselves or others, of personal nature security measures, and therapeutic proto- or to property, and refusing to accept nec- cols. The characteristics of the patient essary medical treatment, can be admit- population (sociodemographic aspects, ted to the adequate establishment’; 2. index offenses, duration of the security Admission (to said establishment) is per- measures and therapeutic protocols) help mitted when someone who carries an identify the patients’ needs and how to acute psychiatric anomaly lacks the re- allocate the resources. quired insight to evaluate the sense and scope that lack of treatment would have, Polypharmacy is an obvious aspect of the as it relates to consent and how the ab- care provided to these patients. This can sence of treatment would be evidenced in raise clinical and ethical questions on a a deterioration of their condition (translat- patient basis in relation to their ability to ed by the authors) [13]. Thus, involuntary consent to treatment and the accumulative hospitalization is an adequate answer be- side effects; however, this also speaks to fore two distinct situations: 1) the patient the difficulty in treating some individuals may be a danger to themselves or other whose mental disorder is associated with people; and 2) the patient does not have violent behaviour. Therefore, a follow-up enough insight to understand the meaning study should look in detail at patients re- and scope of the consent, and the lack of ceiving polypharmacy, in order to identify treatment deeply deteriorates his/her men- its pros and cons and if this fulfils both the tal health. Involuntary treatment is speci- goals of managing public safety and pro- fied in the 3rd section of Article 11 of the moting rehabilitation. It is necessary to same law and states that the committed think of the secure ward as a health pro- patient has to undergo the medically indi- duction space, trying to solve the patients’ cated treatments, without prejudice to the problems, and not as a place of mere dis- provisions of Article 5 (2). This provision ease management or “dangerous states”. relates to [13]. This implies that the simple principle of being involun- tarily admitted is sufficient to force treat- Conflict of Interest: none ment. In the forensic situation, the patients Acknowledgements: The authors report that this are in fact under an involuntary admission, study follows the recommendation of the Declara- tion of Helsinki.

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Corresponding author Teresa Carvalhão, Centro Hospitalar e Universitário de Coimbra, Praceta, R. Prof. Mota Pinto 3075, Coimbra, Portugal - email: [email protected]

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