Predictors of Mental Health Review Tribunal (MHRT) outcome in a forensic inpatient population: a prospective cohort study

Abstract

Background: Previous studies have investigated factors associated with outcome at Mental Health Review Tribunals (MHRTs) in forensic psychiatric patients; however, dynamic variables such as treatment compliance and substance misuse have scarcely been examined, particularly in UK samples. We aimed to determine whether dynamic factors related to behaviour, cooperation with treatment, and activities on the ward were prospectively associated with outcome at MHRT.

Methods: At baseline, demographic, clinical, behavioural, and treatment-related factors were ascertained via electronic medical records and census forms completed by the patient's clinical team. Data on MHRTs (i.e., number attended, responsible clinician's recommendation, and outcome) were collected at a 2-year follow-up. Logistic regression analyses were performed to determine factors associated with outcome among those who attended a MHRT within the follow-up period. Of the 135 forensic inpatients examined at baseline, 79 patients (59%) attended a MHRT during the 2-year follow-up period and therefore comprised the study sample. Of these 79 patients included in the current study, 28 (35%) were subsequently discharged.

Results: In univariable analyses, unescorted community leave, responsible clinician's recommendation of discharge, and restricted Mental Health Act section were associated with a greater likelihood of discharge at MHRT; whilst inpatient aggression, a recent episode of acute illness, higher total score on the Historical Clinical Risk - 20 (HCR-20), higher HCR-20 clinical and risk scores, and agitated behaviour were negatively associated with discharge (p < 0.05). In multivariable analyses, HCR-20 clinical scale scores and physical violence independently predicted outcome at tribunal after controlling for other dynamic variables.

Conclusion: By identifying dynamic factors associated with discharge at tribunal, the results have important implications for forensic psychiatric patients and their clinical teams. Our findings suggest that by reducing levels of agitated behaviour, verbal aggression, and physical violence on the ward, achieving unescorted community leave, and targeting specific items on the HCR-20 risk assessment tool, patients may be able to improve their changes of discharge at a MHRT.

Keywords: First Tier Tribunal; Forensic inpatient; Medium secure unit; Mental Health Review Tribunal; Mentally disordered offender.