Transcript Medico-legal Breakfast Seminar 19 April 2016

Mental Health and the Criminal
Justice System
What to do if your client has a mental health problem
Dr Nuwan Galappathie MBChB MRCPsych MMedSc LLM
Consultant Forensic Psychiatrist
St Andrew’s Healthcare, Birmingham
Visiting Researcher, Institute of Psychiatry, Kings College, London
Contents
• Recognise mental health problems in
offenders
• Manage offenders with mental health
problems
• Instruct an Expert Witness
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Mental Disorder and Offending
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Mental Disorder and Offending
• Small link between mentally disorder and
violence (Walsh et al 2002)
• Violent acts against strangers are rare but
attract large amounts of media interest
• More likely to assault family members
• MDOs more likely to be victims of violence,
homelessness and financial abuse (Walsh et
al 2003)
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Diagnosis using an Internationally
Recognised Classificatory System
Schizophrenia in films
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Schizophrenia in the news
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Schizophrenia
– A syndrome characterised by abnormalities in
thinking, perception, inappropriate or blunted
affect and bizarre behaviour.
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Schizophrenia
– Positive Symptoms
• Hallucinations / Command hallucinations
• Delusions
• Thought Disorder
– Negative Symptoms
• Blunted affect/emotion
• Low motivation, Avolition
• Poor social skills, impaired self care
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Schizophrenia
• Presentation: prodromal, acute then chronic
• Prevalence 1%
• Link with substance misuse
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Major Mood Disorders
• Depression
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Mild depression
Moderate depression
Severe depression
Severe depression with psychotic symptoms
• Bipolar Affective Disorder
– Hypomania
– Mania with psychotic symptoms
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Depression
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Low mood
Reduced energy
Poor concentration
Guilt / unworthiness
Bleak views re: future
Disturbed sleep eg initial, middle or late
insomnia
• Thoughts / acts of self harm
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Depression
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Anhedonia
Reduced emotional reactivity
Early morning wakening
Mood worse in morning
Psychomotor retardation / agitation
Loss of appetite
Weight loss
Loss of sexual interest
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Psychotic depressive symptoms
• Hallucinations
– Mood congruent
• Delusions
– Nihilistic delusions
– Delusions of poverty
– Hypochondriacal delusions
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Bipolar affective disorder
• A major mood disorder:
• Symptoms include:
– Significant disturbance in mood, elevation of mood, low mood,
decreased energy and activity
– Irritability
– Dis-inhibition
– Promiscuity
– Insomnia
– Overspending
– Mood congruent psychotic symptoms
• Auditory hallucinations
• Grandiose delusions
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Personality Disorder
• Deeply engrained and enduring patterns of
behaviour
• Develops in childhood / adolescence and
continues into adulthood
• Not diagnosed before age 16 / 17 / 25
• Pervasive
• Significant personal / occupational / social
distress
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Personality Disorder
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Paranoid
Schizoid
Dissocial
Emotionally unstable
Histrionic
Anankastic
Anxious (avoidant)
Dependent
nb Narcissistic (DSM) / Psychopathic disorder
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Learning Disability
• Arrested / incomplete development of the
mind
• Arises within the developmental period
• Global impairment of skills acquired within
the developmental period
• IQ below 70
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Autistic Spectrum Disorder
• Pervasive Developmental Disorder
• Impaired communication, social interaction,
• restricted & repetitive activities and interests
– Impaired eye contact
– Abnormal / excessive gesturing
– Lack of social awareness
– Can be high functioning
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ADHD – Hyperkinetic Disorder
• Hyperactivity
• Inattention
• Impulsivity
• Childhood / Adult
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PTSD – Post Traumatic Stress Disorder
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Trauma
Hyper vigilance
Flashbacks
Avoidance
Anxiety / Depression
Alcohol / Substance misuse
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Alcohol & Substance Misuse
• Dependence Syndrome
– Compulsion
– Control
– Tolerance
– Reduced activities
– Withdrawal symptoms
– Psychological / physical harm
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Sleep Disorders
Managing Offenders with Mental Health
Problems – Where to get help with treatment
• In the Community
– GP / AE
– Community Mental Health Team
– Drug & Alcohol Services
• At the Police Station
– Force Medical Examiner
– Criminal Justice Liaison Service
– Appropriate adult (for police interview)
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Managing Offenders with Mental Health
Problems – Where to get help with treatment
• In Prison
– Prison Medical Officer
– Prison Mental Health Inreach Team
– Visiting Psychiatrist
• In Hospital
– Responsible Clinician
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Managing Offenders with Mental
Health Problems – Medico Legal Issues
• Fitness to plead and stand trial
– The common law test for fitness to plead remains
that set down in the case R v Pritchard 1836
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M (John) [2003] EWCA Crim 3452, [2003] All ER (D) 199. See the
CP, paras 2.53 to 2.56,
• Defendant should be found unfit to plead if
any one or more of the following was beyond
his capability:
– (1) understanding the charge(s);
– (2) deciding whether to plead guilty or not;
– (3) exercising his or her right to challenge jurors;
– (4) instructing solicitors and/or advocates;
– (5) following the course of proceedings; and
– (6) giving evidence in his or her own defence.
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Court Adaptations
• Intermediary
• Court
– Increased breaks
– Sit out of dock
– Special measures: advice to counsel
– Youth offenders – Live links
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Sentencing – offenders under disability
• If found to have committed the act or made
the omission
– No prison sentence
– Nb – “proceeds of crime”
– Section 35 MHA 1983 admission for report
– Section 38 Interim Hospital Order 5A CPIA
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Sentencing – offenders under disability
• If found to have committed the act or made
the omission
– Section 37 Hospital Order / CPIA
– Section 37 Hospital Order + Section 41 Restriction
Order / CPIA
– Supervision Order (+/- condition treatment /
residence
– Absolute Discharge
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Managing Offenders with Mental
Health Problems – Medico Legal Issues
• Mental State at the time of the offence
• Psychiatric defences
– Diminished Responsibility (partial defence to
Murder)
– Insanity
– Automatism ( Sane/ Insane )
• Capacity to form intent
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Managing Offenders with Mental Health Problems
Sentencing Recommendations
• Risk Assessment
– Violence
– Sexual offending
– Fire setting
• Community Disposal
– Mental health treatment in the community
– Condition of Mental Health Treatment
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Managing Offenders with Mental Health Problems
Sentencing Recommendations
• Hospital Order
– High Secure Hospitals
– Medium Security
– Low Security
– Specialist Services
• Eg Autistic Spectrum Disorder Service
• Learning Disability Service
• Brain Injury Service
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Managing Offenders with Mental Health Problems
Sentencing Recommendations - Hospital
• REMAND:
– S35 (Remand to Hospital by Court for psychiatric report)
– S36 (Remand to Hospital by Court for treatment)
– S48 (Transfer of Remanded Prisoner to Hospital for urgent treatment)
• DISPOSAL by COURT:
– S37 (hospital order and applies to the transfer of individuals from
prison to hospital)
– S37/ S41 (Restriction order)
– S38 (interim treatment order)
– S45A (Hybrid - Hospital Order and Prison Sentence)
• SENTENCED PRISONER
– S47 (hospital treatment) / S49 (Restriction order)
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Managing Offenders with Mental Health Problems
Sentencing Recommendations
• Prison
– Effects of Prison Sentence on Mental Health
– Ability to benefit from treatment and
rehabilitation within prison
– Risk of self harm / suicide within prison
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Instructing an Expert
Email: [email protected]
Instruction Enquiries should include:
Patient details – Initials, age, gender.
Any diagnosis of Personality Disorder, mental health condition or
Learning Disability.
Brief outline of the case background and what you want the report to
assess.
The location where the assessment will need to take place – is the client
on remand or can they travel to St Andrew’s?
The submission date for the report.
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Instructing an Expert
• Instructions should be posted to:
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• Consultancy Service, St Andrew’s, Billing Road, Northampton, NN1 5DG
or sent via the email address: [email protected]
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• We need a full letter of instruction, the full prosecution bundle (Charge
sheet, MG5 case summary, witness statements, PNC report) and copies of
any previous psychiatric or psychological reports, as well as any medical
records. In most instances medical records will need to be seen by the
clinician, so please request these as soon as possible.
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• If you have any queries about instructing St Andrew’s Consultancy
Service, please call us on 01604 616070
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