ORIGINAL RESEARCH published: 03 April 2020 doi: 10.3389/fpsyt.2020.00258 Exploring Needs and Quality of Life of Forensic Psychiatric Inpatients in the Reformed Italian System, Implications for Care and Safety Ellen Vorstenbosch 1,2,3* and Luca Castelletti 4 1 Unitat de Recerca, Docència i Innovació, Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Spain, 2 Sant Joan de Déu Research Foundation, Barcelona, Spain, 3 Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain, 4 Dipartimento di Salute Mentale, Azienda Ulss 9 Scaligera, Verona, Italy The Italian forensic psychiatric system underwent drastic reforms. The newly developed facilities are inspired by psychiatric community services, embracing a recovery-oriented approach. Needs and quality of life are broader concepts that consider the more rehabilitative and humanitarian aspects of treatment. In one of the new Italian forensic psychiatric services, this cross-sectional study aimed to investigate the needs and quality of Edited by: life of forensic psychiatric patients. A second aim was to validate the Italian version of the Birgit Angela Völlm, Forensic inpatient Quality of Life questionnaire Short Version (FQL-SV). Overall, 42 forensic University of Rostock, psychiatric patients were assessed using the Forensic version of the Camberwell Germany Assessment of Need (CANFOR), the Historical-Clinical-Risk-Management-20 (HCR-20), Reviewed by: Harry G. Kennedy, the FQL-SV, and the World Health Organization Quality of Life (WHOQoL-Bref). Patients Trinity College Dublin, reported significantly fewer needs, whether met or unmet, than their treating clinicians. The Ireland Marije E. Keulen-de Vos, general level of agreement between patients and clinicians on specific needs was low Forensic Psychiatric Center (FPC), Kappa values were < .40 for 64% of the total needs and 46% of the unmet needs. Risk Netherlands factors according to the HCR-20 mean scores were 13.1, 4.6, and 6.4 for the historical, *Correspondence: clinical and risk management subscale. Quality of life was moderate to high for 74% of the Ellen Vorstenbosch e.vorstenbosch@pssjd.org patients. Our results showed that lower numbers of needs, whether reported by patients or clinicians, were associated with a better quality of life. The Italian FQL-SV had a Cronbach's Specialty section: alpha of 0.86 and correlated as expected with the WHOQoL-Bref. The FQL-SV is a valid This article was submitted to Forensic Psychiatry, and reliable tool, justifying its use for routinely assessing QoL in Italian forensic psychiatric a section of the journal services. This study enhances our understanding of needs and quality of life of forensic Frontiers in Psychiatry psychiatric patients and how their assessment could have an additional value for recovery- Received: 17 October 2019 Accepted: 17 March 2020 oriented treatment in forensic psychiatry. Although the detained status of forensic patients Published: 03 April 2020 imposes real limits on the capacity for autonomy and choice, incorporating the patient's Citation: perspective on decision-making processes, in relation to aspects of treatment, care, and Vorstenbosch E and Castelletti L daily life, may have benefits such as a better treatment adherence or therapeutic alliance. (2020) Exploring Needs and Quality of Life of Forensic Psychiatric Inpatients Future research should clarify how routinely assessing needs and quality of life can in the Reformed Italian System, contribute to the recovery of these forensic psychiatric patients. Implications for Care and Safety. Front. Psychiatry 11:258. Keywords: forensic psychiatry, needs, quality of life, recovery-oriented treatment, Residenze per l'Esecuzione delle doi: 10.3389/fpsyt.2020.00258 Misura di Sicurezza, forensic psychiatric patients, Italy Frontiers in Psychiatry | www.frontiersin.org 1 April 2020 | Volume 11 | Article 258 Vorstenbosch and Castelletti Forensic Psychiatric Inpatients’ Needs and QoL INTRODUCTION needs and the needs for safety (9). Given these unique rehabilitative needs, Dorkins & Adshead (10) foresee four In 2008, after a warning from the council of Europe for violation problems for the recovery-approach in forensic settings: the of human rights because of poor quality of care and living values and identity of forensic psychiatric patients, social conditions, the Italian government approved a major reform of exclusion as a community response to trauma and violence, mental health care for forensic psychiatric inpatients. The empowerment for those who misuse power and do not respect Decreto della Presidenza del Consiglio dei Ministri (DPCM/ the choices of others, and hopelessness and the offender identity. 2008) transferred all responsibilities for general and mental This limits how much primacy can be given to the perspective of health care both in prisons and the Ospedali Psichiatrici the patient relative to that of professionals (7) and how far Giudiziari (OPG; Forensic Psychiatric Hospitals) from the recovery-oriented treatment can be fully deployed in forensic Ministry of Justice to the National Health Service (NHS). All psychiatric services. forensic psychiatric inpatients, hospitalized at that time in the Notwithstanding, two concepts in line with the recovery- OPGs, were gradually discharged and transferred to ordinary oriented approach that also consider the rehabilitative and psychiatric NHS settings or newly established Residenze per humanitarian aspects of treatment are needs and Quality of Life l'Esecuzione della Misura di Sicurezza (REMS) (1). This process (QoL) (11). In forensic psychiatry, the notion of need has principally got a definite acceleration with Law 81/2014, which established been directed by risk reduction and management (12). To reduce the definite closure of the six national OPGs by the 1st of April the risk of reoffending, treatment focuses on dynamic risk factors 2015 (2). The last patients discharged from an OPG were those in directly linked to criminal behaviors (e.g. substance abuse, antisocial Barcellona P.d.G. (ME) in February 2017. Currently, there are 35 personality, pro-criminal attitudes). These dynamic risk factors are new REMS with security measures that host up to 600 referred to as criminogenic needs. In recent years, there has been an patients (3). emerging interest in a broader understanding of need (13). To The REMS are intended to better meet the needs of providing ensure comprehensive forensic psychiatric treatment, also general intensive and high-quality mental healthcare under proper or non-criminogenic needs should be addressed (14, 15). The GLM, secure conditions (1). Inspired by psychiatric community for instance, stipulates that non-criminogenic needs such as anxiety, services, the REMS are developed as small-scaled (maximum low self-esteem, and psychological distress, should be necessarily 20 beds) therapeutic environments and built according to the targeted to facilitate the learning of new skills or competencies (16). same characteristics and standards as other psychiatric and Accordingly, a need can be defined in terms of a difficulty or rehabilitation facilities. Staff are exclusively clinicians and impairment that requires an interventions to meet it. In other security is provided physically (e.g. fences, locked and secured words, a need can be defined as the possibility of benefitting from access, technical devices), relationally (high staff-patient ratio treatment (17). Studies in forensic psychiatric services have compared to non-forensic units), and procedurally (e.g. risk identified treatment needs related to psychotic symptoms and assessment and management) (4). The common approach in physical health, but also social and relationship-related areas such the REMS is recovery-oriented treatment. The emphasis lies on as daytime activities and company (18–21). QoL, at a minimum, individualized care pathways, including the patients' individual can be defined as an overall “sense of well-being and satisfaction psychosocial and treatment needs, and consideration of the experienced by people under their current living conditions” (22). index offense. Treatment is mainly aimed at improvement of QoL is a broad concept that encompasses aspects like physical insight, understanding of the disorder and its effects, reduction of functioning (e.g. ability to perform daily activities), psychological symptoms, strengthening familiar and services' networks, and functioning (e.g. emotional and mental well-being), social ensuring a therapeutic alliance (5). functioning (e.g. relationships with others and participation in Recovery-oriented treatment in forensic psychiatry is social activities), and perception of health status, pain and overall challenging. It entails engaging patients in their life, on the satisfaction with life (23). Generally, it is considered to consist of basis of their own goals and strengths, and supporting them to objective (resource availability and objective life conditions) and find meaning and purpose through constructing or reclaiming a subjective indicators (individual's evaluation of his or her life) (24). valued identity and social roles (6). Patients should be Objective and subjective QoL are different constructs. Improvement empowered to become self-determined and, hence, be actively of objective indicators does not necessarily enhance the subjective involved in decision-making and treatment-planning. Due to the evaluation and differences in subjective QoL can not necessarily be nature of the patient population, their potential risk of recidivism explained by objective indicators (25, 26). Studies among forensic and the restrictiveness of the system and facility, implementing psychiatric patients have shown that a better QoL was related to recovery-oriented treatment in forensic psychiatry is (leisure) activities, living environment and health (27–29). complicated (7). Forensic psychiatric patients have mental Overall, the empirical evidence on needs and QoL in forensic health difficulties and functional impairment, but also present psychiatric patients is scarce. Studies in general psychiatry, a history of criminal behavior, violent or sexual offending, a high however, have shown that the concepts seem to be related. prevalence of comorbid personality disorder, behavior Higher levels of unmet needs were associated with lower disturbance, self-harm, and substance use (8). Treatment is subjective QoL (30). This association sustained over time and thus related to a patient's clinical and psychopathological needs predicted subjective QoL at a one-year follow-up (31). but should also take into account the balance between his/her Furthermore, needs and QoL can vary significantly among Frontiers in Psychiatry | www.frontiersin.org 2 April 2020 | Volume 11 | Article 258 Vorstenbosch and Castelletti Forensic Psychiatric Inpatients’ Needs and QoL forensic psychiatric patients, reflecting the wide heterogeneity of MATERIALS AND METHODS this specific psychiatric population (32–34). For instance, lower levels of global functioning were associated with higher numbers Study Setting and Data Collection of unmet needs (35, 36) and patients with severe mental illness The study was conducted at the Veneto REMS in Nogara (VR), were significantly more satisfied with their QoL than patients with Italy. This REMS has been open for admission since January a personality-disorder admitted at the same clinic (37). 2016 and is functioning in its full capacity since June 2016. The The newly developed REMS, with a central role for the patient REMS offers forensic psychiatric care to male and female adults in his or her treatment and care planning, could profit from from the Veneto region, covering approximately a catchment systematically assessing needs and QoL. The assessment may area of 4.9 million people. The Veneto REMS is hosted in a help to identify problematic or unsatisfying aspects in a patient's Verona NHS building, a former small suburban hospital, now life, to ascertain what aspects can be improved and eventually mainly converted into an outpatient service. The wards of the monitor the patient's progress. The patient's perception of their REMS are taken from previous inpatient general medical service, daily lives, their experiences in the REMS and their perception of with a fenced garden open during daytime for most of the these experiences (38), are key in their willingness to change. patients. The Veneto REMS has a capacity of 40 beds, divided Patients shall be reluctant to change aspects in life they are over two wards. Rooms are mainly single and double and are satisfied with, whereas not addressing aspects they are unsatisfied unlocked all day round. The current facility is temporary, as the with might jeopardize the therapeutic alliance (39). Veneto Region is planning to entirely renovate the in- and Disagreement on needs and QoL outcomes can be an outdoor spaces from near facilities. indication for the need to negotiate treatment goals. Treatment The population is essentially composed of patients from the focused on needs and QoL favors the individual approach and Veneto region, except for homeless people, in that case, the crime monitoring their outcomes fosters tailoring interventions within site defines the place of admission. Those admitted are generally particular domains. Additionally, discussing needs and QoL on a convicted for a serious offense, and deemed by local courts not regular basis supports the dialogues between patient and responsible for the index delict for reason of insanity (Art. 88 clinician, betters the therapeutic alliance and even enhances c.p.) or alternately considered partially responsible (Art. 89 c.p.), the patient's experienced QoL (40, 41). Systematic assessment for which a psychiatric security measure is applied at the end of of treatment needs and QoL may provide information for the correctional penalty, generally reducing its length one third. treatment planning in addition to other relevant outcomes All admitted patients have an Axis one diagnosis and frequently such as the risk of criminal recidivism, reduction of psychiatric comorbidity on Axis II, defined according to the DSM-5 (45). symptoms, psychological functioning, etc. The majority of the patients are well-known by psychiatric The Italian forensic reform stresses the importance of community services, and only a few have never been in contact developing pathways of care at low levels of therapeutic with the local mental health services. Those who were previously security and focused on recovery-based determinants. known often had a difficult engagement with services and many Rooted in Articles 3 and 46 of the National Constitution, it of them had at least one community treatment order affirms the primacy of health, physical and mental rights for (Trattamento Sanitario Obbligatorio) to recover from a severe citizens, as well as the duty of the Republic to guarantee mental state and personal unavailability to be treated. proper treatments in adequate environments for all its This study is part of ongoing routine outcome measuring citizens. In this light, assessment of needs and QoL assumes (ROM) in a cohort of Italian forensic psychiatric inpatients a priority task to measure the quality of services, and the residing at the Veneto REMS and should be considered as a capacity to target therapeutic programs. Moreover, it provides first measurement. The data for the current study were collected complementary information for management decisions, the between June 2018 and July 2019. The assessments were type of treatment and/or the most suitable facility (42). conducted within the framework of routine care and treatment Finally, the Italian forensic psychiatric system and its recent planning by the patients' treating key-clinicians. To let patients reforms have been described extensively (2, 43). However, the become aware of his/her current QoL and needs profile, and the lack of studies supported by data is considered an eminent gap staff to collect enough information, assessments took place within the Italian system (5), and several authors stress the between the 3rd and 12th month after admission. At the time importance of systematically collecting data for service of the study, seven patients (17%) had not completed the evaluation (1, 44). CANFOR interview; two were discharged before the interview This study, therefore, aimed to present the first results of a could take place and five were only recently admitted. comprehensive set of measurements to routinely monitor Completion of the QoL instruments was supported by the recovery-oriented treatment at the Veneto REMS in Nogara clinician in case a patient suffered dyslexia, illiteracy, or poor (VR). More specifically, 1) we present the results of needs and concentration; otherwise, patients were asked to complete the QoL assessment, and 2) their relationship with other concepts questionnaires by themselves. Clinical and demographic data such as risk assessment and global functioning. A third aim was were obtained from file reviews by one of the key-treating to assess the validity of the Italian translation of the FQL-SV, an clinicians (L.C.). Socio-demographic and clinical variables such instrument developed for the assessment of QoL within forensic as primary diagnoses were collected from the REMS' register of psychiatric inpatient services. admissions. Scores on the Global Assessment of Functioning Frontiers in Psychiatry | www.frontiersin.org 3 April 2020 | Volume 11 | Article 258 Vorstenbosch and Castelletti Forensic Psychiatric Inpatients’ Needs and QoL (GAF) (45) and the HCR-20 Violence Risk Assessment Scheme there are currently serious difficulties in that area (score “2”). The (HCR-20V3) (46) are part of the ROM dataset established at the total need score is the sum of the number of identified met and REMS. Information about index offenses was derived from the unmet needs (scores “1” and “2”). If a need is not considered to criminal register. be present, it can be scored as no need (score “0”) or, in certain For the purpose of the reliability and validity analyses of the instances, not applicable (code “8”) or not known (code “9”). For Italian version of the FQL-SV, the data from the Veneto REMS the purpose of analysis, these scores were combined because were combined with data from the OPG in Castiglione delle some clinicians rated no problem (score “0”) when they did not Stiviere (Mantua, Lombardy). The data from the OPG were know about a patient's need, whereas others rated not applicable collected in December 2015 when the OPG had just started its or not known (code “8” or “9”). Any differences between the reforms. At that time, only one unit met the requirements of a patient and clinician in the perception of a need are apparent by REMS. However, due to its small scale, this unit was being used directly comparing the scores. as an admission ward; therefore, the data from this ward were excluded from analyses. At the remaining wards resided 40, 70, Violence Risk Factors and 50 patients, respectively. Patients were invited to participate Violence risk factors (i.e. criminogenic needs) were assessed with by their treating clinicians, either the patient's psychologist or the Italian version of the Historical-Clinical-Risk-Management- psychiatrist. The exclusion criteria were: inability to complete the 20 Version 3 (HCR-20V3) (50). The HCR-20 is a structured questionnaires due to psychotic episodes and/or major chance of instrument that assesses the potential risk of violence and has decompensation as judged by the clinician, insufficient mastery demonstrated to be a reliable and valid instrument in forensic of the Italian language or seclusion. Overall, 70 patients were psychiatric populations (51, 52). The HCR-20V3 contains 20 approached; 54 (76.2%) were willing to participate and 16 items that are divided over three subscales: 10 historical items, (22.8%) refused. In case a patient suffered dyslexia, illiteracy or five clinical items, and five risk management items. The historical poor concentration, completion of instruments was supported by items are fixed and non-modifiable, conversely clinical and risk the clinician, otherwise, the patient was asked to complete the management are dynamic, can change with the evolution of the questionnaires by themselves. patient's state. Each item is judged by a professional and rated according to whether it is present (score “2”), possibly or Ethical Considerations partially present (score “1”) or absent (score “0”). The total Since assessments were conducted within the framework of HCR-20V3 and three subscales are calculated based on the sum of routine care by patients' treating key-clinicians, approval was these scores, The HCR-20 has shown to be a valid risk sought from the Clinical Directors. Privacy of the patients and assessment instrument in forensic psychiatric populations (53) clinicians was assured conform the policy of the institutions. and findings support the concurrent validity and interrater Data were transferred to the researchers in a fully anonymized reliability of Version 3 of the HCR-20 (54). form; therefore, all statistical analyses were conducted on fully anonymous data. Written informed consent was provided by all Quality of Life (QoL) participants and all patients were informed of their right to QoL was measured using a translation of the Forensic inpatient withdraw consent at any time. The study was approved by the Quality of Life-Short Version (FQL-SV) (28) and the Italian Comitato Etico di Verona (Ethics Committee of Verona). version of the World Health Organization Quality of Life Brief Version (WHOQOL-Bref) (55). The FQL-SV is an abbreviated Variables and Instruments form of the FQL (29), developed for the assessment of QoL Needs within a forensic psychiatric inpatient setting. The FQL-SV Needs were assessed with the Forensic version of the Camberwell consists of 18 QoL items plus one item on acceptance of living Assessment of Need (CANFOR) (47). The CANFOR is designed in a secure unit for some time, which are all scored on a 100- to identify the needs of forensic psychiatric patients. It is millimeter VAS-scale. Patients are asked to indicate their level of considered to be a valid and reliable needs assessment agreement with the specific item (0=total disagreement; instrument (20, 48) and has been translated and validated for 100=total agreement). The total FQL-SV is based on the mean use in forensic psychiatric services in Spain, Portugal and Italy score of the 18 QoL items. The FQL-SV has shown good (19, 36, 49). Through a partially structured interview, the psychometric properties (e.g. Cronbach's alpha of.79) (56). CANFOR integrates the patient's and clinician's perspective on Together with a contributor (S.G.), one of the authors (L.C.) 25 domains of frequent or important problem areas for forensic translated the English version of the FQL-SV into Italian. A back patients. If there have been no difficulties in a particular area, a translation was performed by another contributor (G. T.) and need is scored as not present (score “0”). If there were some checked for consistency by the first author, who also developed difficulties in a certain area, the need can either be met or unmet. the original FQL (E.V.). Based on a revision with 3 clinicians and A met need means that due to an appropriate intervention there the authors, some minor changes were made to meet the reality are currently no difficulties in that area (score “1”). An unmet of the OPG setting in Castiglione delle Stiviere. Specifically, one need means that no interventions are currently being provided or sub-item was added in the sociodemographic part regarding the that the provided interventions are not perceived as effective; number of patients in the department; item 10 about the received Frontiers in Psychiatry | www.frontiersin.org 4 April 2020 | Volume 11 | Article 258 Vorstenbosch and Castelletti Forensic Psychiatric Inpatients’ Needs and QoL opportunities concerning sexuality was simplified into “Are you RESULTS satisfied with your sexual life?” because the initial wording was considered ambivalent. Participants The WHOQoL-Bref (57) consists of 26 items measured with a In this study, 42 forensic psychiatric inpatients consented to five-point Likert scale. The WHOQOL-Bref is considered reliable participate and 35 of them completed all assessments. The among male adults in a forensic psychiatric hospital with majority of the participants were male (88.1%; n=37) and the Cronbach's alphas ranging between.77 and.79 for the domains mean age was 42 years (range 22–62). At the moment of and.80 for the total WHOQOL-Bref (58). Following the criteria assessment, patients resided on average 44 months in forensic of the World Health Organization, four domains, namely psychiatric services (range 2–360). Female patients were Physical health, Psychological health, Social relations, and significantly older than male patients (mean ± SD=50.0 ± 5.8 Environment, were calculated and transformed to a 0–100 vs. 40.6 ± 11.0 years, p=0.02), but did not differ significantly scale (59). Due to the restricted environment of the REMS, the regarding admission time. participating patients cannot make use of public transportation; All patients had one diagnose on Axis I and frequent therefore, item 25 of the WHOQoL-Bref was excluded from comorbidity with an Axis II diagnosis (n=26, 61.9%). With this study. respect to their primary diagnosis, the most frequent diagnosis was schizophrenia (n=28; 66.7%), followed by personality disorder (n=8; 19.0%) and organic psychoses (n=6; 14.3%). Analyses GAF scores ranged from 26 to 58 with a mean (± SD) score of Basic descriptive analyses were conducted to describe the sample's 44.1 (± 7.8). No significant differences were found in age, time of socio-demographic, clinical and forensic characteristics, treatment admission or GAF-score for primary diagnoses. The majority needs, risk factors, and QoL. To evaluate differences in these of patients had a substance abuse diagnosis (n=26; 61.9%). variables independent-sample t-tests and analyses of variance Patients with a diagnosis of substance abuse were significantly (ANOVA) or Mann-Whitney U tests and Kruskal-Wallis tests younger than those who were not diagnosed as such (38.4 ± 9.9 were used, depending on whether the distribution of variables was vs. 46.3 ± 10.5, p=0.03); no significant differences were found with normal or non-normal as determined by the Shapiro–Wilk test. respect to admission time or GAF score. Intra-class correlation coefficients (ICC) were calculated, using a Concerning index offenses, the vast majority had committed two-way mixed model defining, to assess inter-rater reliability for an offense against a person (n=32; 76.2%). More specifically, 17 the CANFOR total needs, total met needs and total unmet needs, as patients committed physical abuse (40.5%), nine homicide recommended by Leese (2001) (60). Cohen's Kappa coefficients (21.4%), and six were convicted for attempted murder (14.3%). were calculated to assess the level of agreement on each need The rest of the patients (n=10; 23.8%) committed other offenses domain between patients and clinicians. Each CANFOR item was such as arson, stalking, burglary or robbery. No significant recoded into two domains: identified need (whether met or unmet) differences were found for index offense with respect to age, and identified unmet need. According to Landis and Koch (1977) time in forensic psychiatric services and GAF-score. At the time (61), Kappa coefficient results to be poor (< 0.21), fair (0.21–0.40), of this study, not all instruments were registered for all patients; moderate (0.41–0.60), good (0.61–0.80) and very good (0.81–1.0). hence, the number of patients who completed the CANFOR, Since the Italian version of the FQL-SV had not been validated FQL-SV, WHOQoL-Bref, and HCR-20V3, is included in Table 1. yet, we explored its internal consistency and construct validity. Internal consistency was examined by calculating Cronbach's alpha Needs (62); a Cronbach's alpha greater than 0.7 has been considered Needs satisfactory (63). Construct validity was assessed by calculating The outcomes of the CANFOR assessment are presented in Figure Pearson correlations between the items of the FQL-SV and the 1. It shows the mean (± SD) number of total, met and unmet needs domains of the WHOQoL-Bref. Both instruments are intended to reported by patients and their clinicians. Compared to their measure the same underlying construct, therefore, we expected to clinicians, patients reported a significant lower number of total find moderate to strong correlations between the FQL-SV items and needs (12.5±3.1 vs. 7.1±2.9; p < 0.01), met needs (8.5±2.5 vs. 4.3±2.2; the WHOQoL-Bref domains. However, the FQL-SV is developed p < 0.01) and unmet needs (4.1±1.9 vs. 2.8±1.9; p < 0.01). specifically for use in a forensic psychiatric inpatient setting. Hence, Table 2 shows for each CANFOR domain the number and we expected to see discrepancies as well. Pearson's correlations percentages of needs (regardless of whether the need was met or of.10–.30 were seen as weak,.30–.50 moderate and > .50 strong (64). unmet) and unmet needs identified by patients and their Due to deviations of normality of some variables, Spearman clinicians as well as the corresponding level of agreement and correlation coefficients were used to assess the relationship Kappa coefficient. The most common need reported by patients between needs (CANFOR), QoL (FQL-SV), risk (HCR-20V3) was daytime activities (71.4%; n=25), followed by psychological and clinical variables. Results were considered significant using distress (60.0%; n=21) and benefits (57.1%; n=20). The most the default of p=0.05 or lower. The data analyses for this paper common needs according to clinicians were psychological were generated using SAS software, Version 9.4 and SPSS distress (97.1%; n=34), accommodation (94.3%; n=33), and Statistic, Version 23. daytime activities, psychological symptoms and company (all Frontiers in Psychiatry | www.frontiersin.org 5 April 2020 | Volume 11 | Article 258 Vorstenbosch and Castelletti Forensic Psychiatric Inpatients’ Needs and QoL TABLE 1 | Characteristics of patients admitted to the Veneto REMS (N=42). n (%) Min-Max Women 5 (11.9) Age (Mean±SD) 41.7±10.9 22-62 Country of birth Italy 29 (69.0) Germany 2 (4.8) Morocco 2 (4.8) Romania 2 (4.8) Other 7 (16.7) Education Primary school 4 (9.5) Secondary school 22 (52.4) High school 14 (33.3) Degree—University degree 2 (4.8) Primary diagnosis Schizophrenia 28 (66.7) Personality disorder 8 (19.0) Organic psychoses 6 (14.3) Comorbid diagnosis on Axis II 23 (54.8) Diagnosis of substance abuse 26 (61.9) FIGURE 1 | Results of the CANFOR needs assessment: mean number of GAF score (Mean±SD) 44.1±7.8 26-58 total, met and unmet treatment needs identified by patients and clinicians at Index offense the Veneto REMS (N=35). CANFOR, Camberwell Assessment of Need; Physical abuse 17 (40.5) REMS, Residenze per l'Esecuzione della Misura di Sicurezza. Homicide 9 (21.4) Attempted murder 6 (14.3) Other (e.g. arson, stalking, burglary, robbery) 10 (23.8) Number of other patients at the unit 19 Violence Risk Factors Number of patients to share bedroom with 1 0-2 The mean (±SD) scores on the HCR-20V3 and its subscales are Months in forensic psychiatric services (Mean±SD) 43.9 ± 65.8 2-360 Previous contact with local mental health services 34 (80.9) presented in Figure 2. The mean (± SD) total HCR-20 score was At least one community treatment order 26 (61.9) 24.2±5.6 (range 13-36). The mean (± SD) scores on the HCR-20 Instruments subscales were as follows: historical items 13.1±3.8, clinical items CANFOR 35 (83.3) 4.6±1.8, and risk items 6.4±1.5. FQL-SV 42 (100) WHOQoL-Bref 37 (88.1) HCR-20V3 42 (100) Quality of Life Internal Consistency and Construct Validity of the SD, standard deviation. Italian FQL-SV The internal consistency and construct validity of the Italian 91.4%; n=32). Intimate relationships (42.9%; n=15), benefits FQL-SV were tested with data from 91 patients from two forensic (40.0%; n=14) and company (39.4%; n=13) were the needs that psychiatric clinics: the Veneto REMS (n=37) and the Castiglione were most frequently reported as unmet by patients. According delle Stiviere OPG (n=54). No significant differences were found to clinicians, these were accommodation (74.3%; n=26), intimate between the REMS and OPG populations with respect to gender relationships (54.3%; n=19) and company (51.4%; n=18). (women 13.5% vs. 27.8%), age (mean ± SD=41.8 ± 11.4 vs. 39.1 ± Kappa coefficients for the CANFOR domains showed that 11.9 years) and admission time (mean ± SD=48.9 ± 68.6 vs. agreement on the total needs was very good for two domains 28.1 ± 31.5 months; all p > 0.05). (8%; sexual oppression, basic education), good for two domains The Cronbach's alphas of the FQL-SV and WHOQoL-Bref were (8%; childcare, benefits), moderate for 5 domains (20%; living 0.86 and 0.79, respectively. In general, the FQL-SV items and environment, physical health, safety to self, drugs, intimate WHOQoL-Bref domains are associated in a coherent and relationships), fair for six domains (24%; food, daytime expected manner (Table 3). For example, social relations, other activities, safety to others, alcohol, money, treatment) and poor residents, daily staff, and affection as well as sexuality correlated to none for six domains (24%; accommodation, self-care, positively and significantly with the WHOQoL-Bref social relations psychotic symptoms, information, psychological distress, and domain, meaning that a more positive evaluation on the social items company). The agreement for unmet needs was very good for of the FQL-SV was related to a higher appraisal of the social one domain (4%; basic education), good for three domains (12%; relations as assessed with the WHOQOL-Bref. Residence 1—feeling safety to self, alcohol, sexual oppression), moderate for three safe, and 2—pleasant environment, daily staff and affection domains (12%; psychotic symptoms, intimate relationships, correlated strongly with the WHOQoL-Bref domain environment. childcare), fair for four domains (16%; food, daytime activities, This means that patients who felt safe at the unit, considered to live psychological distress, company) and poor to none for two in a pleasant environment and those who were positive about their domains (8%; accommodation, benefits). daily contact with staff were also more satisfied with their Frontiers in Psychiatry | www.frontiersin.org 6 April 2020 | Volume 11 | Article 258 Vorstenbosch and Castelletti Forensic Psychiatric Inpatients’ Needs and QoL TABLE 2 | Results of the CANFOR needs assessment at the REMS in Veneto (N=35). Total needa Unmet need b b Patients Clinicians Agreement % Kappa (SE) Patients Clinicians Agreement % Kappa (SE) n (%) n (%) n (%) n (%) 1. Accommodation 19 (53.3) 33 (94.3) 61.8 0.15 (0.10) 8 (22.9) 26 (74.3) 38.2 0.01 (0.10) 2. Food 7 (20.0) 16 (45.7) 68.6 0.34 (0.14) 1 (2.9) 5 (14.3) 88.6 0.30 (0.24) 3. Living environment 12 (34.3) 21 (60.0) 74.3 0.52 (0.12) 1 (2.9) – 97.1 NA 4. Self-care 1 (2.9) 15 (42.9) 60.0 0.08 (0.07) – 2 (5.7) 94.3 NA 5. Daytime activities 25 (71.4) 32 (91.4) 80.0 0.38 (0.16) 6 (17.1) 15 (42.9) 68.6 0.31 (0.14) 6. Physical health 15 (42.9) 13 (37.1) 77.1 0.53 (0.15) 2 (5.7) – 94.3 NA 7. Psychotic symptoms 15 (42.9) 32 (91.4) 52.9 0.14 (0.08) 3 (8.6) 1 (2.9) 94.1 0.48 (0.31) 8. Information 13 (37.1) 31 (88.6) 48.6 0.14 (0.07) 6 (17.1) 6 (17.1) 71.4 -0.01 (0.17) 9. Psychological distress 21 (60.0) 34 (97.1) 57.1 -0.06 (0.05) 7 (20.0) 11 (31.4) 71.4 0.26 (0.17) 10. Safety to self (self-harm) 4 (11.4) 8 (22.9) 82.9 0.41 (0.19) 2 (5.7) 1 (2.9) 97.2 0.65 (0.32) 11. Safety to others (violence) 5 (14.3) 10 (28.6) 74.3 0.26 (0.17) 2 (5.7) – 94.3 NA 12. Alcohol 7 (20.0) 19 (54.3) 60.0 0.24 (0.12) 1 (2.9) 2 (5.7) 97.2 0.65 (0.32) 13. Drugs 9 (25.7) 16 (45.7) 80.0 0.58 (0.13) 1 (2.9) – 97.1 NA 14. Company 18 (51.4) 32 (91.4) 54.6 0.01 (0.09) 13 (37.1) 18 (51.4) 60.6 0.23 (0.16) 15. Intimate relationships 16 (45.7) 21 (60.0) 74.9 0.49 (0.14) 15 (42.9) 19 (54.3) 77.1 0.55 (0.14) 16. Sexual oppression 13 (37.1) 17 (48.6) 90.9 0.82 (0.10) 11 (31.4) 17 (48.6) 84.9 0.69 (0.12) 17. Childcare 5 (14.3) 6 (17.1) 91.4 0.68 (0.17) 4 (11.4) 6 (17.1) 88.6 0.54 (0.20) 18. Basic education 5 (14.3) 7 (20.0) 94.3 0.80 (0.13) 1 (2.9) 1 (2.9) 100 1.00 (0.00) 19. Telephone 4 (11.4) – 88.2 NA – – 100 NA 20. Transport – 14 (40.0) 60.0 NA – – 100 NA 21. Money 5 (14.3) 18 (51.4) 62.9 0.27 (0.11) – 2 (5.7) 94.3 NA 22. Benefits 20 (57.1) 22 (62.9) 82.9 0.64 (0.13) 14 (40.0) 9 (25.7) 62.9 0.18 (0.16) 23. Treatment 9 (25.7) 22 (62.9) 62.9 0.34 (0.11) – 1 (2.9) 97.1 NA 24. Sexual offences – – 100 NA – – 100 NA 25. Arson – 1 (2.9) 97.1 NA – – 100 NA a ‘Total needs' includes met and unmet needs (CANFOR score “1” and “2”). “Need not present, not applicable and not known (CANFOR score “0” and code “8” and “9”, respectively) were considered as no need; bFor the patient-rated needs there were some missing cases (i.e. Accommodation, Psychotic symptoms, Telephone, Sexual offences (one missing case), Company and Sexual oppression (two missing cases); SE: Standard Error; NA: Not applicable test because the domain was rated as no need category by either the patients or clinicians, or both. FQL-SV QoL Assessment The outcomes of the QoL assessment are presented in Figure 3; it shows the mean (± SD) scores on the QoL items assessed with the FQL-SV. The mean (± SD) score on the total FQL-SV was 63.9 ± 16.7 (ranging from 34.2 to 94.4). The aspects patients were most satisfied with were affection (83.5 ± 3.4), daily staff (76.4 ± 3.7) and health 2—overall health (75.3 ± 4.1). Overall, four aspects had a mean score below 50, signifying that patients were unsatisfied with sexuality (39.8 ± 6.3), nutrition (42.1 ± 5.3), residence 2—pleasant environment (48.3 ± 4.7) and activities (49.8 ± 4.5). Considering equal percentiles for low, moderate and high QoL, 26% of the patients at the Veneto REMS reported a low QoL (FQL-SV < 51.3), 31% a moderate QoL (51.3≤FQL-SV < 65.9), and 43% a high QoL (FQL-SV≥65.9). The FQL-SV also includes one item on acceptance of living in a secure unit for some time. This is not part of QoL measurement but considered FIGURE 2 | Results of the HCR-20 risk assessment at the Veneto REMS important in the context of forensic psychiatric treatment. The (N=42). HCR-20, Historical-Clinical-Risk-Management-20; REMS, Residenze mean (± SD) score on this item was 70.4(± 34.8). per l'Esecuzione della Misura di Sicurezza. Relationship Treatment Needs, Risk Factors and Quality of Life environment according to the WHOQoL-Bref assessment. Finally, Spearman rank-order correlations were calculated to explore the the FQL items nutrition, hygiene, and self-actualization showed relationship between needs (CANFOR), risk factors (HCR-20V3), weak correlations, as these are not considered in the QoL (FQL-SV) and clinical variables such as acceptance of WHOQoL-Bref. residing in a forensic psychiatric unit for some time, length of Frontiers in Psychiatry | www.frontiersin.org 7 April 2020 | Volume 11 | Article 258 Vorstenbosch and Castelletti Forensic Psychiatric Inpatients’ Needs and QoL TABLE 3 | Construct validity; correlations between subscales of the FQL-SV and admission, and global functioning (GAF). The correlation matrix WHOQOL-Bref (N=91). showing the significant relationships is presented in Table 4. WHOQoL-Bref domains Summarized, the significant results showed that patient-reported unmet needs correlated positively with the HCR-20V3 historical Physical Psychological Social Environmenta items. With respect to clinician-reported needs, the total and relations unmet needs (CANFOR) correlated positively with the total FQL-SV items HCR-20V3 and the historical and clinical subscales whereas 1. Activities .31** .34** .19 .27** met needs (CANFOR) correlated only positively with the 2. Leaveb .28* .16 .25* .32** historical and clinical HCR-20V3 subscales. 3. Residence 1 .17 .13 .17 .51** (Safety) Total and unmet needs (CANFOR), reported by either the 4. Residence 2 .26* .20 .16 .51** patient or the clinician correlated negatively with QoL (FQL-SV). (Pleasant No such relation was seen for met needs. Concerning risk factors, environment) as assessed with HCR-20V3, the total score and the clinical and 5. Nutrition .01 .13 .02 .13 historical subscale correlated negatively with QoL (FQL-SV). 6. Hygiene .20 .04 -.02 .19 7. Health 1 .39** .25* .38** .44** This was not found for the HCR-20V3 risk subscale, which did (Mental health correlate negatively but that correlation was non-significant. treatment) Clinician-reported total and unmet needs (CANFOR), 8. Health 2 .32** .32** .18 .17 furthermore, correlated negatively with acceptance of residing in a (Overall health) 9. Sexuality .16 .26* .63** .18 forensic psychiatric unit for some time. QoL (FQL-SV), on the other 10. Social relations .24* .32** .34** .37** hand, correlated positively with acceptance of stay. Needs, risk 11. Other residents .33** .19 .34** .40** factors, nor QoL correlated significantly with the length of 12. Daily staff .40** .28** .34** .55** admission in forensic psychiatric services. Finally, only risk factors 13. Affection .31** .31** .44** .53** in the form of the total HCR-20V3 score and the clinical subscale 14. Autonomy 1 .34** .33** .18 .49** (Move freely) correlated negatively with global functioning (GAF). 15. Autonomy 2 .24* .25* .20 .33** (Make own decisions) 16. Self- .18 .23* .21 .10 DISCUSSION actualization 17. Religion .32** .30** .45** .30** Main Findings 18. Overall QoL .40** .55** .53** .40** This study presents the first outcomes of needs and QoL Pearson correlations: ** Correlation is significant at the 0.01 level (two-tailed), * Correlation assessment among forensic psychiatric patients admitted to is significant at the 0.05 level (two-tailed). one of the newly-developed Residenze per l'Esecuzione della Moderate and strong correlations are shown in bold typeface (r ≥.3). Misura di Sicurezza (REMS) in Italy. To our knowledge, this is a Item 25 of the WHOQoL-bref has been excluded as it assesses access to public the first study in the reformed Italian forensic facilities transport, which is not applicable for this population. b Twenty-two patients skipped the FQL-SV item regarding satisfaction with their current investigating these concepts in a structured way. The present leave status (n=79). study employed comprehensive measures for the evaluation of FIGURE 3 | Mean scores of the FQL-SV QoL assessment at the Veneto REMS (N=42); Seven patients skipped the item regarding satisfaction with current leave status (n=34). FQL-SV, Forensic inpatient Quality of Life questionnaire Short Version; QoL, Quality of Life; REMS, Residenze per l'Esecuzione della Misura di Sicurezza. Frontiers in Psychiatry | www.frontiersin.org 8 April 2020 | Volume 11 | Article 258 Vorstenbosch and Castelletti Forensic Psychiatric Inpatients’ Needs and QoL TABLE 4 | Correlation matrix of the relationships between the CANFOR-S, FQL-SV, HCR-20 and clinical variables (N=42). 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 CANFOR Total needs (Patient) – 2 CANFOR Met needs (Patient) .73** – 3 CANFOR Unmet needs (Patient) .67** .03 – 4 CANFOR Total needs (Clinician) .47** .16 .46** – 5 CANFOR Met needs (Clinician) .39* .21 .28 .76** – 6 CANFOR Unmet needs (Clinician) .23 -.04 .38* .57** -.04 – 7 Total HCR-20V3 .25 .04 .29 .53** .26 .46** – 8 HCR-20V3 Historical scale .30 .06 .36* .61** .39* .41* .93** – 9 HCR-20V3 Clinical scale .16 -.01 .20 .53** .34* .37* .82** .70** – 10 HCR-20V3 Risk scale -.00 .03 -.09 -.10 -.26 .18 .39* .12 .21 – 11 FQL-SV -.40* -.07 -.47** -.64** -.29 -.58** -.59** -.54** -.49** -.27 – 12 Acceptance of stay -.09 .10 -.17 -.39* -.14 -.37* -.13 -.13 -.20 .03 .59** – 13 Length of admission .29 -.02 -.02 .10 .03 .16 .17 .15 .21 .00 -.14 -.15 – 14 GAF -.15 -.16 -.01 -.17 -.15 -.13 -.39** -.24 -.63** -.13 .01 -.22 -.23 – Spearman rank order correlations: ** Correlation is significant at the 0.01 level (two-tailed), * Correlation is significant at the 0.05 level (two-tailed). Moderate and strong correlations are shown in bold typeface (r ≥.3). Patient and clinician scores on the CANFOR (n = 35); FQL-SV, HCR-20V3 (sub-) scale(s) and clinical variables Acceptance of stay, Length of admission and GAF (n=42). recovery-oriented treatment such as needs (CANFOR) and had a mean score >50). Moreover, 74% of the patients reported a quality of life (FQL-SV) and investigated the interrelationship moderate to high QoL. The aspects patients were least content between the CANFOR, FQL-SV, and measures of risk factors about were sexuality, nutrition, pleasant environment, and (HCR-20V3) and clinical variables such as global functioning. activities. Despite the compulsory nature of admission to the Concerning total needs, the patients at the Veneto REMS REMS, patients were relatively satisfied, which might also explain reported a comparable number as their counterparts in a the relatively high score on acceptance of residing in a forensic medium-security hospital in the United Kingdom and secure psychiatric unit for a while. mental health services in Australia (15, 20). In our study, Compared to their clinicians, the patients in our study however, the proportion of unmet needs was slightly lower (7.1 underreported the number of needs, whether met or unmet. needs, of which 2.8 were unmet). It means that 39% of the areas Here it's worth noting that the findings of earlier CANFOR in which patients experience difficulties have not yet been studies are inconclusive. Our results are in line with the findings resolved 3 to 12 months after admission to the REMS. The from Pillay and colleagues (69), who found a structural under- areas of unmet needs were similar to those in other studies (15, reporting by patients across units with different levels of 18); namely, those in the personal and social areas such as therapeutic security. Thomas and colleagues (20) and a study intimate relationships and company. Contrary to previous by Abou-Sinna and Luebbers (18) also found that patients studies (15, 18–20), our patients reported benefits as a reported significantly fewer total needs than their professionals. common and unmet need, meaning that they experience With respect to unmet needs, however, Abou-Sinna and difficulties with the financial support they are entitled to and Luebbers (2012) found a non-significant difference, Thomas that the help they currently receive is insufficient. The clinicians and colleagues (2008) omitted to report whereas others found in our study reported a mean of 12.5 needs, of which 4.1 were that patients reported significantly more unmet needs than their considered as unmet. Although these numbers are considerably professionals (15, 18, 20, 36). Some of these studies (18, 69), higher than in earlier European studies (15, 18–20), a recent furthermore, reported moderate to strong correlations between Australian study by Adams and colleagues (65) showed that the patient- and staff-reported needs. In our study, moderate total needs were comparable to patients residing in open or low- correlations were found for total and unmet needs but not for security facilities (13.2 and 13.5, respectively). However, the met needs. Moreover, the level of agreement between patients number of unmet needs was closer to that of patients residing and clinician in our study was moderate to good on 36% of the in high security (4.6). Psychological distress, accommodation, identified needs (nine out of 21 Kappa values were > .40) and on daytime activities, psychotic symptoms, and company were the 54% of the unmet needs (seven out of 13 Kappa values were most common needs whereas accommodation, intimate > .40). To the best of our knowledge, no CANFOR studies have relationships and company were most often considered as reported per need the level of agreement between patient and unmet. These results were largely in line with other studies clinician in a forensic psychiatric setting. In general psychiatry, (15, 19, 20, 49, 66). The practice of violence risk assessment however, comparably low levels of agreement were found (70, and management has recently been introduced in Italy, 71). Better levels of agreement were found, as might be expected, concurrently with the reformed system (3). The risk factors in in areas with a more objective response (e.g. basic education, our study, measured with the HCR-20, were characteristic for sexual oppression and childcare). forensic psychiatric populations elsewhere (67, 68). The results of Higher numbers of patient-rated unmet needs were associated the FQL-SV showed that patients at the Veneto REMS were with higher scores on the HCR-20 historical subscale, which is satisfied with the vast majority of QoL aspects (78% of the items generally considered as the static or actuarial part of the instrument, Frontiers in Psychiatry | www.frontiersin.org 9 April 2020 | Volume 11 | Article 258 Vorstenbosch and Castelletti Forensic Psychiatric Inpatients’ Needs and QoL expressing only fixed, non-modifiable variables. This is an Limitations important finding, as patient-reported needs were not related to The current study has a number of important limitations. First, the HCR-20 clinical and risk subscales, meaning that the the number of patients included in this study was small, which correlations are displayed only for past events and problems but might limit its representativeness for the whole forensic not for current or future personal aspects. This supports previous psychiatric population in Italy. On the other hand, all REMS findings regarding the CANFOR (18); namely, that it provides consist of small-scale units with maximum of 20 beds and the unique information about patients' criminogenic and non- authors have no reason to believe that there are regional criminogenic treatment needs. Consistent with other studies (18), differences in those admitted to the REMS (3). Second, the higher numbers of clinician-rated needs were associated with higher small population did not allow us to investigate the group risk, according to the HCR-20 historical and clinical subscales. This differences of needs and QoL, whereas previous research has might be expected, as both instruments capture the same shown that male and female patients report different needs perspective, namely the patient's current state of recovery profiles and various primary diagnoses showed differences in according to the clinician. Furthermore, HCR-20V3 clinical items QoL appraisal (33, 34, 37, 74). Third, the data were collected as investigate the current situation, and are those more contiguous part of routine care by their treating key-clinicians. Patients with the CANFOR's treatment needs. might have given desirable responses to convince their clinicians Understanding patients' needs is essential to improving their of treatment progress. Fourth, this is the first time the data of the subjective QoL. Our study showed that a decrease in numbers of established ROM battery have been analyzed and not all available needs, and not solely a decrease in unmet needs, reported both by data were included. Therefore, the current study has provided the patient and the clinician, are associated with higher levels of valuable insights for further development of the Veneto REMS' QoL. Likewise, lower numbers of risk factors, specifically those ROM battery and dataset. Fifth, many patients were admitted at on the HCR-20 historical and clinical subscales, enhances QoL. the same time (opening of REMS beginning 2016), this caused This result is in line with studies conducted in general psychiatry that some patients resided already several (3 to 12) months or outpatient communities (71, 72). Nevertheless, further before these first assessments took place. Further development of research is indicated, as this relation seems only longitudinal the ROM should, therefore, also involve establishing fixed for patient-rated unmet needs or the social domain of treatment assessment moments to be able to link the findings to the needs (31, 73). Higher numbers of clinician-reported total and different phases of treatment and recovery. Sixth, our study did unmet needs were associated with lower levels of acceptance of not include any measure to assess criterion validity. This limits residing in a forensic psychiatric unit for some time. This the assumptions that can be made about the (long-term) effect of relation, however, might have been influenced by the treatment addressing needs and QoL and how these concepts might phase of a patient. Patients with less (unmet) treatment needs are contribute to the effectiveness of recovery-oriented treatment. generally considered closer to discharge from the REMS, which might make it easier to accept their admission than for patients Implications for Research recently admitted. Acceptance of stay, on the other hand, was First, the current study could only investigate cross-sectional positively correlated with QoL, meaning that higher levels of associations for treatment needs, risk factors, and QoL. Future acceptance are associated with a more positive QoL appraisal. ROM data will be of longitudinal nature; hence, these data might None of the measures was associated with the duration of time provide more insight in how meeting needs and QoL that patients have been admitted to forensic psychiatric services. improvement might be related to progress in recovery-oriented Finally, quality of life was assessed with the Italian version of the treatment. Second, our ROM dataset lacked a measure of need FQL-SV. Although the original version showed good psychometric for therapeutic security. This could have given information about properties, the Italian translation had not been validated yet. To that whether the patients in the REMS are comparable to forensic purpose, the Veneto REMS also included the WHOQoL-Bref in the psychiatric patients elsewhere in Europe (e.g. TBS hospital in the battery of ROM instruments. The internal consistency of the Italian Netherlands or forensic psychiatric hospital in Ireland, the UK or FQL-SV was good; the Cronbach's alpha was 0.86, which was higher Germany). Third, future research is also needed on more than in the original version (28). Construct validity with the objective indicators in forensic psychiatric settings. Our ROM WHOQoL-Bref was largely in accordance with the results dataset did not allow us to control for more objective indicators presented by Schel and colleagues (2016). Positive relations were such as leave status, received treatment interventions, treatment found between FQL-SV items and WHOQoL-Bref domains that phase, level of restrictiveness, social contacts, (aggressive) were expected to assess comparable underlying constructs. incidents; some of these aspects might have had an intervening However, these relations were of moderate magnitude, effect on the relationships between needs, QoL, and risk factors. underlining the assumption that the FQL-SV and WHOQoL-Bref Fourth, more research is needed on the level of agreement differ in their conceptualization of QoL. Though test-retest between patient- and clinician-rated outcomes. Especially in reliability would be needed to further validate the FQL-SV, the relation to recovery-oriented treatment, where the therapeutic current study has made it plausible that the FQL-SV is a valid and alliance is key to successful treatment. More insight is needed on reliable tool to assess QoL, justifying its use for routinely assessing the aspects that interfere here in order to improve the level of QoL at the REMS. agreement and facilitate recovery-oriented treatment in forensic Frontiers in Psychiatry | www.frontiersin.org 10 April 2020 | Volume 11 | Article 258 Vorstenbosch and Castelletti Forensic Psychiatric Inpatients’ Needs and QoL psychiatry. On the other hand, recovery-oriented treatment in chronic mental disorders (86). This is the case for general forensic psychiatry has many challenges (75–79), and empirical psychiatry as well as forensic psychiatry, though in the latter evidence on how to deploy the concept is scarce. Nevertheless, more caution is needed as patients might try to influence their the lack of substantial, quantitative research should not imply legal status through giving desirable responses and presenting a further postponement of investigating evidence-based recovery- better version of themselves (87). oriented interventions from general psychiatry and how these Finally, some specific aspects deserve attention in forensic could be further developed for the forensic psychiatric field. psychiatric services. Social needs are frequently unmet in populations with restrictions of personal freedom. Hence, Implications for Practice efforts should be made for community interventions enabling Far from being a simple humanitarian approach to guarantee a patients to get to know people, and improve their social skills and better stay for those admitted, needs and quality of life provide relational abilities. Sexuality in forensic psychiatric services is substantial information to support pathways of care and the often neglected or considered complicated by staff and necessary practice of risk assessment and management. management, and therefore avoided (88). Studies in general Qualitative studies have shown that recovery in forensic psychiatry have shown that half of the patients never spoke or psychiatry, apart from public safety, can have a broad range of seldom spoke about sexual functioning with their healthcare treatment outcomes (78). For instance, patients define recovery in professionals (89). In forensic psychiatric services, many patients terms of a normal, independent, compliant, healthy, meaningful, are of an age that is considered critical in an individual's and progressing life (80). The additional value of addressing needs development of adult sexuality and personal relationships. and QoL, apart from the more obvious ethical reasons such us Although policies should be developed in this context, a start respect for dignity and rights, may lie in incorporating the patient's could be made by recognizing sexuality as a need and discuss it as perspective. Although the detained status of forensic patients part of treatment planning. Another important aspect is imposes real limits on the capacity for autonomy and choice, satisfaction with daytime or leisure activities, which has been incorporating the patient's perspective on decision-making associated with higher QoL (27, 29, 90). However, daytime processes, in relation to aspects of treatment, care, and daily life, activities in forensic psychiatry are often characterized by might have notable benefits. Being involved may give patients a passive leisure (e.g. watching television) and rest (91). Patients sense of self-efficacy and responsibility, increase their motivation feel to only have the choice between participating in occupational and treatment adherence, improve the therapeutic alliance and give activities and refusing to participate, and that refusing to clinicians a better idea of the patients' insight into their risk factors. participate could prejudice their discharge possibilities (92). Nevertheless, here it should be mentioned that our study did not Nonetheless, it is recognized that patients are more likely to include an outcome measure for successful treatment (e.g. discharge enjoy self-chosen occupations; they prefer to spend time engaged from the REMS). Although needs and QoL assessment might in activities that they value, enjoy and feel they do well (91). In provide additional information for treatment planning, it cannot line with the recovery paradigm, patients should be consulted be concluded that it helps to reduce patients' future risk of regarding their preferences and involved in the organization of recidivism or readmission to forensic psychiatric services. activities that fulfill them. Research on the effectiveness of involving forensic psychiatric patients in their treatment planning is still in its infancies. Some studies found only limited evidence for involving forensic (out-) DATA AVAILABILITY STATEMENT patients in the decision-making process of risk assessment and The datasets generated for this study will not be made publicly management (81, 82), whereas a recent review study (83) showed available because providing access to these data would be a some favorable support for incorporating patient perspectives, breach of the GPDR and in conflict with the institutional thereby emphasizing the importance of correct instruments to policies. Requests to access the datasets should be directed to guide the patient-clinician collaboration in risk assessment and the corresponding author. treatment planning. This study has shown that the level of agreement on specific needs between patient and clinician is low. Notwithstanding, this is fundamental in recovery-oriented treatment planning. The ETHICS STATEMENT level of agreement seems to improve along the different phases of The study was approved by the Comitato Etico di Verona (Ethics forensic psychiatric treatment, meaning that differences between Committee of Verona). patient and clinician ratings diminish in concordance with movement to lower levels of security (84). Incorporation of the patient's point of view guarantees a more open and sincere AUTHOR CONTRIBUTIONS adherence to treatment and care, it emphasizes empowerment and contributes to the recovery of patients (85). Nevertheless, EV and LC conceived of the presented idea. LC amalgamated the patient-reported outcomes should be interpreted with caution as collected the data. EV processed the anonymized data, they might diverge due to cognitive affections, distortions of the performed the analysis, drafted the manuscript, and designed perception and low insight, typical of people suffering from the figures. LC aided in interpreting the results. Both authors, EV Frontiers in Psychiatry | www.frontiersin.org 11 April 2020 | Volume 11 | Article 258 Vorstenbosch and Castelletti Forensic Psychiatric Inpatients’ Needs and QoL and LC, discussed the results, commented on the manuscript, data on QoL and needs at the Veneto REMS in Nogara (VR). and contributed to its final version. Furthermore, we would like to thank Serena Giglio and Giuseppa Tripi for helping to translate the FQL-SV into Italian and ACKNOWLEDGMENTS Victoria Moneta for her assistance with some of the statistical analyses. Finally, we would like to acknowledge the valuable The authors acknowledge the assistance and help of Isabella cooperation of the patients and the clinical staff of the Barbon, Ilaria Curto, and Martina Meneghelli in collecting the Veneto REMS. REFERENCES Need-Forensic version) for the needs assessment of people with mental health problems in the forensic services. Actas Esp Psiquiatr (2010) 38:129–37. 1. Barbui C, Saraceno B. Closing forensic psychiatric hospitals in Italy: a new revolution 20. Thomas SDM, Slade M, Mccrone P, Harty M-A, Parrott J, Thornicroft G, et al. begins? Br J Psychiatry (2015) 206:445–6. doi: 10.1192/bjp.bp.114.153817 The reliability and validity of the forensic Camberwell Assessment of Need 2. Carabellese F, Felthous AR. Closing Italian Forensic Psychiatry Hospitals in (CANFOR): a needs assessment for forensic mental health service users. Int J Favor of Treating Insanity Acquittees in the Community. Behav Sci Law Methods Psychiatr Res (2008) 17:111–20. doi: 10.1002/mpr (2016) 34:444–59. doi: 10.1002/bsl.2234 21. Thomas S, McCrone P, Fahy T. How do psychiatric patients on prison 3. Castelletti L, Scarpa F, Carabellese F. Treating not guilty by reason of insanity healthcare centres differ from inpatients in secure psychiatric inpatient and socially dangerous subjects by community psychiatric services: An Italian units? Psychol Crime Law (2009) 15:729–42. doi: 10.1080/10683160802516265 perspective. Rass Ital Criminol (2018) 12:182–9. 22. Lehman AF, Zastowny TR. Patient satisfaction with mental health services: A 4. Kennedy HG. Therapeutic uses of security: Mapping forensic mental health meta-analysis to establish norms. Eval Program Plann (1983) 6:265–74. services by stratifying risk. Adv Psychiatr Treat (2002) 8:433–43. doi: 10.1192/ doi: 10.1016/0149-7189(83)90006-X apt.8.6.433 23. Berlim MT, Fleck MPA. “Quality of life”: a brand new concept for research 5. Scarpa F, Castelletti L, Lega I. The Closure of Forensic Psychiatric Institutions and practice in psychiatry. Rev Bras Psiquiatr (2003) 25:249–52. doi: 10.1590/ in Italy. In: Völlm B, Braun P, editors. Long-Term Forensic Psychiatric Care: S1516-44462003000400013 Clinical, Ethical and Legal Challenges. (Springer, Cham: Long-Term Forensic 24. Fakhoury W, Priebe S. Subjective quality of life: It's association with other Psychiatric Care) (2019) 317–30. doi: 10.1007/978-3-030-12594-3_22 constructs. Int Rev Psychiatry (2002) 14:219–24. doi: 10.1080/ 6. Slade M. Mental illness and well-being: The central importance of positive 0954026022014495 psychology and recovery approaches. BMC Health Serv Res (2010) 10. 25. Swinton M, Carlisle J, Oliver J. Quality of life for patients with a personality doi: 10.1186/1472-6963-10-26 disorder – comparison of patients in two settings: an English special hospital 7. Mann B, Matias E, Allen J. Recovery in forensic services: facing the challenge. and a Dutch TBS clinic. Crim Behav Ment Health (2001) 11:131–43. doi: Adv Psychiatr Treat (2014) 20:125–31. doi: 10.1192/apt.bp.113.011403 10.1002/cbm.383 8. Shinkfield G, Ogloff J. Use and interpretation of routine outcome measures in 26. Ruggeri M, Nosè M, Bonetto C, Cristofalo D, Lasalvia A, Salvi G, et al. forensic mental health. Int J Ment Health Nurs (2015) 24:11–8. doi: 10.1111/ Changes and predictors of change in objective and subjective quality of life: inm.12092 multiwave follow-up study in community psychiatric practice. Br J Psychiatry 9. Traverso GB, Ciappi S, Ferracuti S. The treatment of the criminally insane in (2005) 187:121–30. doi: 10.1192/bjp.187.2.121 Italy: An overview. Int J Law Psychiatry (2000) 23:493–508. doi: 10.1016/ 27. Long CG, McLean A, Boothby AJ. Factors associated with quality of life in a S0160-2527(00)00047-9 cohort of forensic psychiatric in-patients. Br J Forensic Pract (2008) 10:4–11. 10. Dorkins E, Adshead G. Working with offenders: Challenges to the recovery doi: 10.1108/14636646200800002 agenda. Adv Psychiatr Treat (2011) 17:178–87. doi: 10.1192/apt.bp.109.007179 28. Schel SHH, Bouman YHA, Vorstenbosch ECW, Bulten BH. Development of 11. Fitzpatrick R, Chambers J, Burns T, Doll H, Fazel S, Jenkinson C, et al. A the forensic inpatient quality of life questionnaire: short version (FQL-SV). systematic review of outcome measures used in forensic mental health Qual Life Res (2016). 26, 1153–61. doi: 10.1007/s11136-016-1461-9 research with consensus panel opinion. Health Technol Assess (2010) 14:1– 29. Vorstenbosch ECW, Bouman YHA, Braun PC, Bulten EBH. Psychometric 108. doi: 10.3310/hta14180 properties of the forensic inpatient quality of life questionnaire: quality of life 12. Looman J, Abracen J. The risk need responsivity model of offender assessment for long-term forensic psychiatric care. Health Psychol Behav Med rehabilitation: Is there really a need for a paradigm shift? Int J Behav (2014) 2:335–48. doi: 10.1080/21642850.2014.894890 Consult Ther (2013) 8:30–6. doi: 10.1037/h0100980 30. Ritsner MS, Lisker A, Arbitman M, Grinshpoon A. Factor structure in the 13. Keulen-de Vos M, Schepers K. Needs Assessment in Forensic Patients: A camberwell assessment of need-patient version: The correlations with Review of Instrument Suites. Int J Forensic Ment Health (2016) 15:283–300. dimensions of illness, personality and quality of life of schizophrenia doi: 10.1080/14999013.2016.1152614 patients. Psychiatry Clin Neurosci (2012) 66:499–507. doi: 10.1111/j.1440- 14. Andrews DA, Bonta J, Wormith JS. The Recent Past and Near Future of Risk 1819.2012.02383.x and/or Need Assessment. Crime Delinq (2006) 52:7–27. doi: 10.1177/ 31. Slade M, Leese M, Ruggeri M, Kuipers E, Tansella M, Thornicroft G. Does 0011128705281756 meeting needs improve quality of life? Psychother Psychosom (2004) 73:183–9. 15. Segal A, Daffern M, Thomas S, Ferguson M. Needs and risks of patients in a doi: 10.1159/000076456 state-wide inpatient forensic mental health population. Int J Ment Health Nurs 32. Shaw J, Davies J, Morey H. An assessment of the security, dependency and (2010) 19:223–30. doi: 10.1111/j.1447-0349.2010.00665.x treatment needs of all patients in secure services in a UK health region. J Forensic 16. Ward T, Stewart C. Criminogenic needs and human needs: A theoretical model. Psychiatry (2001) 12:610–37. doi: 10.1080/09585180127380 Psychol Crime Law (2003) 9:125–43. doi: 10.1080/1068316031000116247 33. Saloppé X, Pham TH. Impact des troubles mentaux sur la qualit?? de vie per?? 17. Wing J, Brewin CR, Thornicroft G. Defining mental health needs. In: ue par des patients issus d'un h??pital psychiatrique s??curitaire. Encephale Thornicroft G, editor. Measuring mental health needs. London: Gaskell/ (2007) 33:892–901. doi: 10.1016/j.encep.2006.12.003 Royal College of Psychiatrists. (1992). pp. 1–17. 34. Pham TH, Saloppé X. Influence of psychopathy on self-perceived quality of 18. Abou-Sinna R, Luebbers S. Validity of assessing people experiencing mental life in forensic patients: a cohort study in Belgium. J Forensic Psychiatry illness who have offended using the camberwell assessment of need-forensic Psychol (2013). 24(1):31–47. doi: 10.1080/14789949.2012.747105 and health of the nation outcome scales-secure. Int J Ment Health Nurs (2012) 35. Castelletti L, Lasalvia A, Molinari E, Thomas SDM, Straticò E, Bonetto C. A 21:462–70. doi: 10.1111/j.1447-0349.2012.00811.x standardised tool for assessing needs in forensic psychiatric population: 19. Romeva GE, Rubio LGG, Güerre SO, Miravet MJR, Cáceres AG, Thomas Clinical validation of the Italian CANFOR, staff version. Epidemiol SDM. Clinical validation of the CANFOR scale (Camberwell Assessment of Psychiatr Sci (2014a) 24:274–81. doi: 10.1017/S2045796014000602 Frontiers in Psychiatry | www.frontiersin.org 12 April 2020 | Volume 11 | Article 258 Vorstenbosch and Castelletti Forensic Psychiatric Inpatients’ Needs and QoL 36. Talina M, Thomas S, Cardoso A, Aguiar P, Caldas de Almeida JM, Xavier M. 57. The WHOQOL Group. Development of the World Health Organization CANFOR Portuguese version: Validation study. BMC Psychiatry (2013a) WHOQOL-BREF quality of life assessment. Psychol Med (1998) 28:551–8. 13:157. doi: 10.1186/1471-244X-13-157 doi: 10.1017/S0033291798006667 37. Swinton M, Oliver J, Carlisle J. Measuring quality of life in secure care: 58. Saloppé X, Thierry E, Pham TH. Validation du WHOQOL-bref en De-fense comparison of mentally ill and personality disordered patients. Int J Soc Sociale version finale.pdf. Psychiatr Violence (2006) 1:1–25. Psychiatry (1999) 45:284–91. doi: 10.1177/002076409904500407 59. University of Melbourne. Quality of Life (WHOQOL) Study Australian 38. Mercier C. Improving the quality of life of people with severe mental Whoqol-100 , whoqol-bref and ca-whoqol instruments user ‘ s Manual and disorders. Soc Indic Res (1994) 33:165–92. doi: 10.1007/978-94-011-0171-4_5 Interpretation Guide. A J Bible Theol (2000) 22. 39. Lehman AF. Measures of quality of life among persons with severe and 60. Leese MN, White IR, Schene AH, Koeter MWJ, Ruggeri M, Gaite L. Reliability persistent mental disorders. Soc Psychiatry Psychiatr Epidemiol (1996) 31:78– in multi-site psychiatric studies. Int J Methods Psychiatr Res (2001) 10:29–42. 88. doi: 10.1007/BF00801903 doi: 10.1002/mpr.98 40. Mccabe R, Hoffmann K, Priebe S, Röder-wanner U. Therapeutic Relationships 61. Landis JR, Koch GG. Agreement of categorical data. Biometrics (1977) 33:159– and Quality of Life: Schizophrenia Patients. Int J Soc Psychiatry (1999) 74. doi: 10.2307/2529310 45:276–83. doi: 10.1177/002076409904500406 62. Cronbach LJ, Meehl PE. Construct validity in psychological tests. Psychol Bull 41. Omer S, Golden E, Priebe S. Exploring the Mechanisms of a Patient- Centred (1955) 52:281–302. doi: 10.1037/h0040957 Assessment with a Solution Focused Approach (DIALOG+) in the 63. Bland JM, Altman DG. Statistics notes: Cronbach's alpha. BMJ (1997) 314:572. Community Treatment of Patients with Psychosis: A Process Evaluation doi: 10.1136/bmj.314.7080.572 within a Cluster- Randomised Controlled Trial. PloS One (2015) 11: 64. Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd. NJ: e0148415. doi: 10.1371/journal.pone.0148415 Lawrence Erlbaum Associates (1988). doi: 10.1192/bjp.111.479.1009-a 42. Harty MA, Shaw J, Thomas SD, Dolan M, Davies L, Thornicroft G, et al. The 65. Adams J, Thomas SDM, Mackinnon T, Eggleton D. The risks , needs and security, clinical and social needs of patients in high security psychiatric stages of recovery of a complete forensic patient cohort in an Australian state. hospitals in England. J Forensic Psychiatry Psychol (2004) 15:208–21. BMC Psychiatry (2018), 1–13. doi: 10.1186/s12888-017-1584-8 doi: 10.1080/14789940410001703967 66. Thomas S, Leese M, Dolan M, Harty MA, Shaw J, Middleton H, et al. The individual 43. De Vito CG. Forensic psychiatric units in Italy from the 1960s to the needs of patients in high secure psychiatric hospitals in England. J Forensic Psychiatry present. Int J Law Psychiatry (2014) 37:127–34. doi: 10.1016/ Psychol (2004) 15:222–43. doi: 10.1080/14789940410001702283 j.ijlp.2013.09.012 67. Douglas KS, Guy LS, Reeves KA, Weir J. HCR-20 Violence Risk Assessment 44. Di Lorito C, Castelletti L, Lega I, Gualco B, Scarpa F, Völlm B. The closing of Scheme: Overview and Annotated Bibliography. (2005). Available at: https:// forensic psychiatric hospitals in Italy: Determinants, current status and future escholarship.umassmed.edu/psych_cmhsr/335/ [Accessed September 30, 2019]. perspectives. A scoping review. Int J Law Psychiatry (2017) 55:54–63. 68. Douglas KS, Shaffer C, Blanchard AJE, Guy LS, Reeves KA, Weir J. HCR-20 doi: 10.1016/j.ijlp.2017.10.004 Violence Risk Assessment - Scheme Overview and Annotated Bibliography. 45. American Psychiatric Association. Diagnostic and Statistical Manual of (2017). Available at: https://kdouglas.files.wordpress.com/2017/06/hcr-20- Mental Disorders. 5th ed. Washington, DC: APA (2013). annotated-bibliography-version-13.pdf [Accessed January 10, 2020]. 46. Douglas KS, Hart SD, Webster C BH. HCR-20 V3, Assessing risk for violence. 69. Pillay SM, Oliver B, Butler L, Kennedy HG. Risk stratification and the care Burnaby: Simon Fraser University. Mental Health, Law, and Policy Institute pathway. Ir J Psychol Med (2008) 25:123–7. doi: 10.1017/S0790966700011228 (2013) 70. Slade M, Phelan M, Thornicroft G, Parkman S. The Camberwell Assessment 47. Thomas S, Harty MA, Parrott J, McCrone P, Slade M, Thornicroft G. The of Need (CAN): Comparison of assessments by staff and patients of the needs Forensic CAN (CANFOR). A Needs Assessment for Forensic Mental Health of the severely mentally ill. Soc Psychiatry Psychiatr Epidemiol (1996) 31:109– Service Users. (2003). 13. doi: 10.1007/BF00785756 48. Vos MK, Schepers K. Needs Assessment in Forensic Patients: A Review of 71. Wiersma D, van den Brink R, Wolters K, McCabe R, Bullenkamp J, Hansson L, Instrument Suites. Int J Forensic Ment Health (2016) 15:283–300. et al. Individual unmet needs for care: Are they sensitive as outcome criterion for doi: 10.1080/14999013.2016.1152614 the effectiveness of mental health services interventions? Soc Psychiatry Psychiatr 49. Castelletti L, Lasalvia A, Molinari E, Thomas SDM, Stratico E, Bonetto C. A Epidemiol (2009) 44:317–24. doi: 10.1007/s00127-008-0432-z standardised tool for assessing needs in forensic psychiatric population: 72. Hansson L, Björkman T. Are factors associated with subjective quality of life clinical validation of the Italian CANFOR, staff version. Epidemiol Psychiatr in people with severe mental illness consistent over time? - A 6-year follow-up Sci (2014b) 24:274–81. doi: 10.1017/S2045796014000602 study. Qual Life Res (2007) 16:9–16. doi: 10.1007/s11136-006-9119-7 50. Caretti V, Scarpa F, Ciappi S, Castelletti L, Catanesi R, Carabellese FF, et al. 73. Lasalvia A, Bonetto C, Malchiodi F, Salvi G, Parabiaghi A, Tansella M, et al. Valutazione del rischio di recidiva di un crimine violento. Firenze: Hogrefe Listening to patients' needs to improve their subjective quality of life. Psychol editor (2019a) Med (2005) 35:1655–65. doi: 10.1017/S0033291705005611 51. Caretti V, Carpentieri R, Caprì C, Schimmenti A. Attendibilità, validità e 74. Archer M, Lau Y, Sethi F. Women in acute psychiatric units, their characteristics proprietà psicometriche della versione italiana dell"HCR-20v3. Firenze: and needs: A review. Psychiatrist (2016) 40:266–72. doi: 10.1192/pb.bp.115.051573 Hogrefe F, editor. (2019b). 75. Pouncey CL, Lukens JM. Madness versus badness: The ethical tension 52. Douglas KS, Hart SD, Webster CD, Belfrage H, Guy LS, Wilson CM. between the recovery movement and forensic psychiatry. Theor Med Bioeth Historical-Clinical-Risk Management-20, Version 3 (HCR-20V3): (2010) 31:93–105. doi: 10.1007/s11017-010-9138-9 Development and Overview. Int J Forensic Ment Health (2014a) 13:93–108. 76. Clarke C, Lumbard D, Sambrook S, Kerr K. What does recovery mean to a doi: 10.1080/14999013.2014.906519 forensic mental health patient? A systematic review and narrative synthesis of 53. Douglas KS, Ogloff JRP, Hart SD. Evaluation of a model of violence risk the qualitative literature. J Forensic Psychiatry Psychol (2016) 27:38–54. assessment among forensic psychiatric patients. Psychiatr Serv (2003) doi: 10.1080/14789949.2015.1102311 54:1372–9. doi: 10.1176/appi.ps.54.10.1372 77. Mezey GC, Kavuma M, Turton P, Demetriou A, Wright C. Perceptions, 54. Douglas KS, Belfrage H. Interrater Reliability and Concurrent Validity of the experiences and meanings of recovery in forensic psychiatric patients. J Forensic HCR-20 Version 3. Int J Forensic Ment Health (2014b) 13:130–9. doi: 10.1080/ Psychiatry Psychol (2010) 21:683–96. doi: 10.1080/14789949.2010.489953 14999013.2014.908429 78. Shepherd A, Doyle M, Sanders C, Shaw J. Personal recovery within forensic 55. De Girolamo G, Rucci P, Scocco P, Becchi A, Coppa F, D'Addario A, et al. settings–Systematic review and meta-synthesis of qualitative methods studies. Quality of life assessment: Validation of the Italian version of the WHOQOL- Crim Behav Ment Health (2016) 26:59–75. doi: 10.1002/cbm.1966 Brief. Epidemiol Psichi atr Soc (2000) 9:45–55. doi: 10.1017/ 79. Simpson A, Penney S. The recovery paradigm in forensic mental health S1121189X00007740 services. Crim Behav Ment Health (2011) 21:299–306. doi: 10.1002/cbm.823 56. Schel SHH, Bouman YHA, Vorstenbosch ECW, Bulten BH. Development of 80. Livingston JD. What Does Success Look Like in the Forensic Mental Health the forensic inpatient quality of life questionnaire: short version (FQL-SV). System? Perspectives of Service Users and Service Providers. Int J Offender Qual Life Res (2017) 26:1153–61. doi: 10.1007/s11136-016-1461-9 Ther Comp Criminol (2018) 62:208–28. doi: 10.1177/0306624X16639973 Frontiers in Psychiatry | www.frontiersin.org 13 April 2020 | Volume 11 | Article 258 Vorstenbosch and Castelletti Forensic Psychiatric Inpatients’ Needs and QoL 81. van den Brink RHS, Troquete NAC, Beintema H, Mulder T, van Os TWDP, 89. Rosenberg KP, Bleiberg KL, Koscis J, Gross C. A survey of sexual side effects Schoevers RA, et al. Risk assessment by client and case manager for shared among severely mentally ill patients taking psychotropic medications: Impact decision making in outpatient forensic psychiatry. BMC Psychiatry (2015) on compliance. J Sex Marital Ther (2003) 29:289–96. doi: 10.1080/ 15:120. doi: 10.1186/s12888-015-0500-3 00926230390195524 82. Troquete NAC, van den Brink RHS, Beintema H, Mulder T, van Os TWDP, 90. O' Flynn P, O' Regan R, O' Reilly K, G Kennedy H. Predictors of quality of life Schoevers RA, et al. Predictive validity of the Short-Term Assessment of Risk among inpatients in forensic mental health: implications for occupational and Treatability for violent behavior in outpatient forensic psychiatric therapists. BMC Psychiatry (2018) 18:16. doi: 10.1186/s12888-018-1605-2 patients. Psychol Assess (2015) 27:377–91. doi: 10.1037/a0038270 91. Stewart P, Craik C. Occupation, Mental Illness and Medium Security: 83. Ray I, Simpson AIF. Shared risk formulation in forensic psychiatry. J Am Acad Exploring Time-Use in Forensic Regional Secure Units. Br J Occup Ther Psychiatry Law (2019) 47:22–8. doi: 10.29158/JAAPL.003813-19 (2007) 70:103–11. doi: 10.1177/030802260707001002 84. Davoren M, O'Dwyer S, Abidin Z, Naughton L, Gibbons O, Doyle E, et al. 92. Craik C, Bryant W, Ryan A, Barclay S, Brooke N, Mason A, et al. A qualitative Prospective in-patient cohort study of moves between levels of therapeutic study of service user experiences of occupation in forensic mental health. Aust security: the DUNDRUM-1 triage security, DUNDRUM-3 programme Occup Ther J (2010) 57:339–44. doi: 10.1111/j.1440-1630.2010.00857.x completion and DUNDRUM-4 recovery scales and the HCR-20. BMC Psychiatry (2012) 12:80. doi: 10.1186/1471-244X-12-80 Conflict of Interest: The authors declare that the research was conducted in the 85. Coffey M. Researching service user views in forensic mental health: A literature review. J absence of any commercial or financial relationships that could be construed as a Forensic Psychiatry Psychol (2006) 17:73–107. doi: 10.1080/14789940500431544 potential conflict of interest. 86. Atkinson M, Ph D, Zibin S, Sc M, Chuang H. Characterizing quality of life among patients with chronic mental. Am J Psychiatry. (1997) 154(1):99–105. Copyright © 2020 Vorstenbosch and Castelletti. This is an open-access article doi: 10.1176/ajp.154.1.99 distributed under the terms of the Creative Commons Attribution License 87. Renwick SJ, Black L, Ramm M. Anger treatment with forensic hospital patients. (CC BY). The use, distribution or reproduction in other forums is permitted, Leg Criminol Psychol (1997) 2:103–16. doi: 10.1111/j.2044-8333.1997.tb00336.x provided the original author(s) and the copyright owner(s) are credited and 88. Tiwana R, McDonald S, Vollm B. Policies on sexual expression in forensic that the original publication in this journal is cited, in accordance with psychiatric settings in different European countries. Int J Ment Health Syst accepted academic practice. No use, distribution or reproduction is permitted (2016) 10:5. doi: 10.1186/s13033-016-0037-y which does not comply with these terms. Frontiers in Psychiatry | www.frontiersin.org 14 April 2020 | Volume 11 | Article 258