Patient characteristics related to length of stay in a UK forensic inpatient sample: a systematic review; and, Examining the validity of the CORE-OM as a measure of distress in a forensic population with severe and enduring mental illness
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Date
01/12/2021Author
MacDonald, Maxine
Metadata
Abstract
Introduction
There is concern that individuals may experience prolonged stays in secure inpatient
settings, and research highlights little convergence on factors associated with length
of stay in the forensic inpatient population. Routine outcome measures are valuable
in monitoring patient progress, including patient self-report measures such as the
Clinical Outcomes in Routine Monitoring – Outcome Measure (CORE-OM). Research
regarding use of the CORE-OM in UK forensic settings is limited. Previous research
found CORE-OM scores for this population fell below clinical cut-offs; the reasons for
which have not yet been examined. A systematic review was conducted to identify
patient factors associated with length of stay in UK medium and high secure settings.
An empirical study investigated the validity of the CORE-OM in a high secure setting,
examining whether poor insight is associated with low self-report distress, as
measured by the CORE-OM, and whether the CORE-OM can adequately capture
distress arising from psychotic experience.
Method
A systematic search of studies investigating factors associated with length of stay in
UK secure settings, between 2000 and 2020, was conducted. Eight studies from
combined search results of 4738 articles, met inclusion criteria. Included studies were
subject to full-text review. Quality assessment was subject to two independent ratings.
In the empirical study, routinely collected CORE-OM and two measures of insight and
symptomatology were retrospectively extracted from case files for 246 males in high
secure inpatient care.
Results
The systematic review found a diagnosis of schizophrenia, previous psychiatric and
forensic admissions, admission from other secure or prison settings, and Section
37/41 under the Mental Health Act (MHA) were significantly associated with longer
stays in secure care. However, significant methodological weaknesses and variability
defining ‘long-stay’ were present across studies. The empirical study found symptom
subscales significantly predicted CORE-OM all item mean scores. Poor insight
predicted higher self-report distress on CORE-OM all item mean scores and did not
mediate the relationship between symptomatology and distress (CORE-OM). Cut-off
scores fell below clinical reference samples and revised normative scores are
provided for a male high secure population.
Discussion
The systematic review found mixed evidence regarding factors associated with length
of stay in forensic secure settings, with clinical variables and MHA status providing the
most consistent associations with length of stay. Research in high secure settings and
with other samples out with England are urgently required to increase generalisability.
Future research should focus on standardisation of predictor variables and
prospectively designed studies that incorporate factors beyond static variables,
including patient self-report measures and dynamic variables. Long-stay definitions
should be considered in line with policy changes. The empirical study found the
CORE-OM is sensitive to changes in clinician-rated symptomatology. Mean CORE-OM scores were below clinical reference samples in the community and revised
normative scores for a high secure forensic sample are provided. Insight did not
explain low self-report as poor insight predicted greater distress on CORE-OM scores.
Future research considering factors associated with change in CORE-OM scores over
time is recommended to investigate the symptoms-insight-distress interactions across
the patient journey.
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