Treatment and evaluation methods used in forensic psychiatry

Background

SBU was commissioned by the Swedish Government to assess methods used for treatment and evaluation in forensic psychiatry in two steps. This evidence map presents the results of the first step of the commissioned project: to identify systematic reviews in forensic psychiatry and determine which domains have not yet been systematically reviewed (scientific evidence gaps). The second phase of the project is to produce systematic reviews for identified scientific evidence gaps where appropriate.

In 2015, 296 people in Sweden were sentenced to forensic psychiatric care. Forensic psychiatric care is sentenced as a consequence of a criminal offense under influence of a severe mental disorder. The care therefore involves incarceration. Release from care is contingent not only on the patient’s health, but must also include an evaluation of their threat to society. Treating patients under compulsion places special demands on health care providers. Patients sentenced to forensic psychiatric care are often young and commonly have more than one psychiatric diagnosis. Substance abuse and other physical comorbidities also occur.

Aims

The aims were to systematically identify high quality systematic reviews assessing the effects and side effects of treatments or evaluation methods used in forensic psychiatric care and map out the scientific evidence gaps in the field. Assessments reporting on the pro­gnostic accuracy of relevant evaluation tools were also included.

Methods

Experts in forensic psychiatry representatives from patient organisations identified relevant domains to be mapped and established inclusion criteria. SBU conducted a literature search for systematic reviews addressing the resulting study questions. SBU together with the project experts assessed the identified systematic reviews for relevance and quality. The results from relevant systematic reviews were compiled.

One important selection criteria for this project was that the forensic psychiatric care was as similar to the Swedish care system as possible. The following domains were included in the systematic mapping: diagnostics, evaluations, pharmacological, psychological or psychosocial interventions, habilitation, rehabilitation, as well as methods for compulsive treatment.

Results

In total, SBU identified four systematic reviews that met the established inclusion criteria in the specified domains. All four identified systematic reviews were judged to be well conducted. However, the review authors reported that they found no studies of sufficiently high quality and were therefore unable to provide a reliable quantitative assessment of the effects or side effects for any of the methods assessed.

Scientific evidence gaps

We identified scientific evidence gaps in the following domains: diagnostics, pharmacological, psychological or psychosocial interventions, rehabilitation, as well as methods for coercive interventions.

The term scientific evidence gap refers to the situation where no systematic review of the scientific evidence is available for a given topic. The fact that there is an evidence gap in a field does not mean that the associated methods have no effect. It simply means that there is a scientific uncertainty about treatment effects and that more studies are needed to provide a reliable measurement.

Interventions used within the field of forensic psychiatry are not completely unresearched as the methods used overlap to a large extent with the methods used in other branches of psychiatric care. In addition, the symptoms of those receiving psychiatric treatment while in custody is similar to the symptoms of those receiving psychiatric treatment in other contexts. However, more research is needed to establish how the treatments effect the patients, and whether the conditions that are specific to forensic psychiatry alter their effect.

Future systematic reviews

Currently SBU have two projects to conduct systematic reviews based on this evidence map; one to assess pharmacological treatments and anther to assess psychological and psychosocial interventions. The projects will also address ethical and health economic aspects as well as the experiences of patients. The reviews are expected to be published in the summer of 2018.