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Forensic Psychiatric Services in Hong Kong.

Forensic psychiatry specialises in the legal aspects of psychiatry and in the assessment and management of mentally disordered offenders. Forensic psychiatrists have expertise in psychiatric fields such as correctional psychiatry, assessment of malingering, and assessment and management of violence risk and dangerousness, as well as legal aspects such as mental health law, criminal law, compilation of court reports, and as expert witnesses.

The rate of psychiatric morbidity (psychosis, neurosis, personality disorder, substance misuse, organic mental disorder) has been reported to be high in remanded prisoners (63% of males and 76% of females) and sentenced prisoners (37% of males and 57% of females). (1,2) The high prevalence reflects the high demand for forensic psychiatry services. The Forensic Psychiatry Department of Castle Peak Hospital (CPH) is the sole provider of full-range specialised psychiatric services in Hong Kong.

In 1875, the first temporary asylum was established in Hong Kong to provide custodial care to mentally ill patients. In 1906, the Asylum Ordinance for 'the detention, custody, and care of persons of unsound mind', was passed by the Legislative Council. In 1928, the term 'lunatic asylum' was substituted by the term 'mental hospital' when the Victoria Mental Hospital came into operation. Psychiatrists from the Victoria Mental Hospital provided visiting psychiatric service to mentally disordered offenders detained in prisons. In 1961, CPH began to receive those remanded or sentenced by court's Hospital Order. In 1972, the Siu Lam Psychiatric Centre (SLPC) became operational under the Correctional Services Department. The SLPC receives mentally disordered offenders sentenced for compulsory in-patient treatment (Hospital Order), remanded prisoners suspected to have psychiatric problems, and prisoners requiring psychiatric assessment and treatment referred by other correctional institutions. In 1995, the Forensic Psychiatry Department of CPH was established to cope with increasing demand.

The Forensic Psychiatry Department of CPH provides visiting generic and forensic psychiatric service to the SLPC. In 1997 a rehabilitation unit was added to the department, and in 2003 a rehabilitation ward was constructed. In addition, two forensic out-patient clinics: Tuen Mun Mental Health Centre and Violet Peel Psychiatric Centre (subsequently moved to Pamela Youde Nethersole Eastern Hospital Psychiatric Outpatient Clinic) were established to provide psychiatric services to high-risk discharged patients. Since 2013, the Forensic Psychiatry Department of CPH has taken up the non-refoulment claim assessment service of torture claimants and asylum seekers upon referral by the Immigration Department.

Mentally disordered patients who have committed a serious crime (eg, murder, wounding with intent, inflicting grievous bodily harm) are admitted to the Forensic Psychiatry Department of CPH for psychiatric assessment. Those assessed to be mentally fit for court hearing are remanded to the SLPC after the first court trial. At the SLPC, further assessment and treatment are provided by visiting psychiatrists who then submit psychiatric reports to the courts. Psychiatrists of the department may be summoned to be expert witnesses. Convicted persons may be sentenced to an in-patient treatment order (Hospital Order) at the SLPC. After serving the Hospital Order or upon the recommendation of the Mental Health Review Tribunal, patients may be transferred to CPH for in-patient treatment and rehabilitation. In addition, persons in custody who present with mental problems can be transferred to the SLPC for psychiatric assessment and treatment, and then transferred to CPH for further management under relevant legal provisions. The two intensive care wards in CPH provide a safe, secure, and therapeutic environment to address the holistic needs of patients with serious risk of violence or behavioural disturbances. The rehabilitation unit devises individualised rehabilitation programmes. After discharge, depending on the result of risk assessment, high-risk patients are followed up at a forensic out-patient clinic with support from the community psychiatric service.

Psychiatrists in the Forensic Psychiatric Department of CPH have expertise in correctional psychiatry, assessment of malingering, and assessment and management of violence risk and dangerousness, as well as mental health law and criminal law.

Correctional psychiatry deals with problems in remanded and sentenced patients such as prison psychosis, personality disorders, substance misuse, propensity for sexual offences, anxiety and depressive symptoms in reaction to prison life, and the stress of legal proceedings. Psychiatrists also provide advice and support to prison doctors and Correctional Services Department staff in the management of mentally disordered offenders in custodial settings.

Assessment of malingering aims to identify prisoners who fake symptoms of mental disorders to evade legal responsibility. A combination of highly skilled clinical assessment, collateral information from round-the-clock observation in custody, and evidence-based assessment tools are used.

Assessment and management of violence risk and dangerousness is performed at both CPH and the SLPC using validated tools. A multidisciplinary collaborative approach is adopted with input from psychiatrists, nurses, clinical psychologists, occupational therapists, and medical social workers.

In addition to their expertise in psychiatry, the psychiatrists at the Forensic Psychiatric Department of CPH also have knowledge of the laws, criminal proceedings, and psychopathology surrounding various crimes and related psychiatric-legal issues, as well as proficiency in court report writing, liaising with prosecuting agencies, Correctional Services Department, and courts, and providing expert witness testimony. These psychiatrists provide assessments of the patients' mental state at the time of the index criminal offence and of the patients' mental competence to plead and stand trial. They also provide opinions on pleas of diminished responsibility or not guilty by reason of insanity, and make recommendations to the court on disposal and treatment options.

The current issue of the East Asian Archives of Psychiatry has a theme on forensic psychiatry. Siu et al. (3) reviewed the characteristics of 4492 mentally ill offenders seen by psychiatrists at the SLPC and explored the current utilisation of forensic psychiatric services as a basis for service review and reform. The sample is representative of the forensic psychiatric services.

Chow et al. (4) conducted the first prospective cohort study in the two largest prison reception centres in Hong Kong to investigate the prevalence of psychiatric disorders in the remanded Chinese population, using the Chinese version of Correctional Mental Health Screen.

In Hong Kong, compulsory admission is governed by the Mental Health Ordinance (Chapter 136) Section 31 (detention of a patient under observation), Section 32 (extension of period of detention of a patient under observation), Section 36 (detention of certified patients), and the sections in Part IV such as those for Hospital Order, Transfer Order, and Removal Order. Siu et al. (5) reviewed the literature and the mental health laws in Hong Kong concerning the 'legal criteria' and 'practical criteria' in the application of compulsory admission by mental health professionals. In addition, the harm principle, the patient's decision-making capacity, and issues of paternalism and patient's liberty were explored.

Liu (6) discussed the recent United Kingdom law reform and reviewed forensic psychiatric practice in Hong Kong on the issue of diminished responsibility. Psychiatrists in the Forensic Psychiatric Department of CPH may be called upon as expert witnesses for partial defence of diminished responsibility for people involved in murder. The relevant statute is Chapter 339 Homicide Ordinance Section 3, which was directly adopted from the Homicide Act 1957 Section 2 of the United Kingdom. The Law Commission in the United Kingdom suggested that a reform in the diminished responsibility plea is necessary. It has brought significant changes in the relevant statute, and the Homicide Act 1957 Section 2 has been replaced by the Coroners and Justice Act 2009 Section 52 (1)-(1B).

Chan and Lam (7) discussed the associations between mental disorder and sexual offending, and described the psychiatric and psychological approaches in the management of sexual offenders in Hong Kong. Offenders, with or without mental disorder, have complex needs that warrant tailor-made services for assessment, care, restoration, rehabilitation, and reintegration into the community. Assessment of re-offending risk and prevention of recidivism are also salient, particularly for sexual offenders.

In the United States, sexual offence laws differ by state. Sexually violent predator (SVP) laws are controversial and tend to be opposed by academics, libertarians, and professional organisations but are supported by state politicians and the United States Supreme Court. Felthous and Ko (8) reviewed early and recent background leading to SVP legislation, systematically reviewed each state and federal SVP law for commonalities and differences, summarised the requirements articulated by the Supreme Court that shaped these laws, and discussed the objectives and potential merits of SVP laws.

Tang et al. (9) reviewed the history, legislation, and psychiatric perspective of infanticide and filicide, examined the characteristics of mothers charged of murdering their own child, and explored the infanticide law in Hong Kong. Data on maternal infanticide and filicide in a psychiatric custodial institution were presented.

Chester (10) described the care and treatment for offenders with intellectual and developmental disorders in the United Kingdom Criminal Justice System. A meta-analysis of sexual offenders found a strong association between low intelligence and paedophilic offences but not for other types of sexual offences. (11) About 11% of those charged with arson has been reported to have learning disability. (12)

References

(1.) Gunn J, Maden A, Swinton M. Treatment needs of prisoners with psychiatric disorders. BMJ 1991;303:338-41.

(2.) Maden A, Taylor CJA, Brooke D, Gunn J. Mental Disorder in Remand Prisoners. London: Home Office; 1995.

(3.) Siu BW, Chan O, Au-Yeung CC, Chow KK, Liu AC, Tang DY, et al. Profiling mentally-ill offenders in Hong Kong: a 5-year retrospective review study. East Asian Arch Psychiatry 2018;28:114-21.

(4.) Chow KK, Chan O, Yu MW, Lo CS, Tang DY, Chow DL, et al. Prevalence and screening of mental illness among remand prisoners in Hong Kong. East Asian Arch Psychiatry 2018;28:134-8.

(5.) Siu B, Fistein EC, Leung HW, Chan L, Yan CK, Lai A, et al. Compulsory admission in Hong Kong: balance between paternalism and patient liberty. East Asian Arch Psychiatry 2018;28:122-8.

(6.) Liu AC. Diminished responsibility: law reform in the United Kingdom and personal perspective on forensic psychiatric practice in Hong Kong. East Asian Arch Psychiatry 2018;28:144-9.

(7.) Chan O, Lam S. Combination of psychiatric and psychological approaches in assessment and treatment of sexual offenders. East Asian Arch Psychiatry 2018;28:129-33.

(8.) Felthous AR, Ko J. Sexually violent predator law in the United State. East Asian Arch Psychiatry 2018;28:159-73.

(9.) Tang D, Siu B. Maternal infanticide and filicide in a psychiatric custodial institution in Hong Kong. East Asian Arch Psychiatry 2018;28:139-43.

(10.) Chester V. People with intellectual and developmental disorders in the United Kingdom criminal justice system. East Asian Arch Psychiatry 2018;28:150-8.

(11.) Cantor JM, Blanchard R, Robichaud LK, Christensen BK. Quantitative reanalysis of aggregate data on IQ in sexual offenders. Psychol Bull 2005;131:555-68.

(12.) Rix KJ. A psychiatric study of adult arsonists. Med Sci Law 1994;34:21-34.

Bonnie Wei-Man Siu, MBChB, FRCPsych, FHKCPsych, FHKAM (Psychiatry), Department of Forensic Psychiatry, Castle Peak Hospital, New Territories, Hong Kong. Email: bonniew114m@yahoo.com

M Lam, MBChB, MRCPsych, FHKCPsych, FHKAM (Psychiatry), Department of General Adult Psychiatry, Castle Peak Hospital, New Territories, Hong Kong.

DOI: 10.12809/eaap1845
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Title Annotation:Editorial
Author:Siu, Bonnie Wei-Man; Lam, M.
Publication:East Asian Archives of Psychiatry
Article Type:Report
Geographic Code:9HONG
Date:Dec 1, 2018
Words:1819
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