Legally insane or not

The majority of defendants undergoing forensic observation have comorbid mental disorders and substance abuse, making the retrospective identification and classification of symptoms a complex clinical task. In order to evaluate the defendant’s legal status, reliable and valid descriptions of psychotic symptoms in the forensic reports are required (28). By improving the quality of the assessments using structured assessment instruments, the basis for decisions regarding the defendant/patient’s placement and later treatment will be strengthened. The best possible assessment will reduce the number of misjudgments; i.e. psychotic sentenced to prison and not psychotic sentenced to treatment. Figures from the Norwegian Criminal Cases Review Commission indicate that it is the first that is the challenge. Research in the field of forensic psychiatric practice is very important to ensure legal protection to this vulnerable group. Persons with severe mental illness and a history of violence and substance abuse represent a group in need of specialized treatment, challenging for both the prison health system and the forensic psychiatric system. Defendants evaluated as psychotic at the time of the crime, can be sentenced to mandatory psychiatric treatment, providing major challenges throughout the treatment chain, regarding both treatment and rehabilitation. Providing the best possible evidence base for correct placement of the defendant is thus highly important for optimal treatment and rehabilitation opportunities. Improvement of assessments will also document if the defendant, in the cases the crime is not severe enough to meet the criteria for sentence to compulsory psychiatric treatment, qualifies to psychiatric treatment due to the Norwegian Mental Health Act. 

Method

This is an exploratory, cross-sectional study of registry data. Five hundred anonymized forensic reports on severe violent offenders from the archives of the Norwegian Board of Forensic Medicine from all the five Norwegian health regions were selected. The material were reports from 2009, 2011, 2013, 2015 and 2018, one hundred from each year, to ensure sufficient statistical power each year and to cover a longer time period.  

The quality and reliability of the psychotic symptom descriptions in the forensic reports were rated using the PANSS instrument. The PANSS instruments is used as a  clinical , in this study the instrument are be scored based on the experts' descriptions of symptomatology in forensic reports. This may lead to some difficulties, for instance regarding the scoring of symptom intensity, as the forensic reports mostly report symptoms dichotomously (present/absent).

Etichs

The Regional Ethics Committee for Medical Research Ethics in South-Eastern Norway Regional Health Authority (REC) did an evaluation of the study and decided it was outside the scope of the Health Research Act (2014/539). As the study objects were the reports, and no personal information regarding the defendants was recorded, informed consent from the defendants was not needed. The Council of Confidentiality and Research with the Ministry of Justice has approved the study, as has the Office of the Attorney General. The NBFM recommended access to reports from their archives and contributed with anonymization of all reports. The Data Protection Officer at the Oslo University Hospital approved the study (2015/2498). The reports and the scoring forms were given a corresponding ID number, and the data are stored anonymized in Oslo University Hospital’s research server.  

Publications

• Løvgren, Pia Jorde; Laake, Petter; Narud, Kjersti; Reitan, Solveig Klæbo; Bjørkly, Stål Kapstø: Are symptoms assessed differently for schizophrenia and other psychoses in legal insanity evaluations of violent crimes?. BMC Psychiatry 2023 ;Volum 23.(1) s. 1-14. 
• Løvgren, Pia Jorde; Laake, Petter; Reitan, Solveig Merete Klæbo; Narud, Kjersti: Use of assessment instruments in forensic evaluations of criminal responsibility in Norway. BMC Psychiatry 2022 ;Volum 22.(1) s. 1-14. 
• Løvgren, Pia Jorde; Laake, Petter; Reitan, Solveig Merete Klæbo; Narud, Kjersti: Assessing psychotic symptoms in forensic evaluations of criminal responsibility–a pilot study using Positive And Negative Syndrome Scale. Journal of Forensic Psychiatry & Psychology 2020 ;Volum 31.(4) s. 490-502.