The Journal of Forensic Psychiatry & Psychology, September 2007; 18(3): 331 341 A study of forensic psychiatric screening reports and their relationship to full psychiatric reports PÅL GRØNDAHL 1, STEIN E. IKDAHL 2, & ALV A. DAHL 3 1 Ullevål University Hospital, University of Oslo, Norway, 2 Office for Forensic Psychiatry, Oslo Police District, Norway, and 3 Rikshospitalet-Radiumhospitalet Medical Centre, University of Oslo, Norway Abstract In Norway the prosecuting authorities can request a forensic psychiatric screening report in order to determine whether a full forensic psychiatric report is required. This study explores three research questions. Are such screening reports considered relevant by the prosecution authorities? To what extent are their recommendations followed? What is the concordance of the conclusions of the screening reports and the full reports? This study analysed the screening reports issued on 419 defendants by Oslo Police District s Office for Forensic Psychiatry in 2002 2005, and the 91 (22%) full reports issued on these defendants. All reports were evaluated using a structured rating form. Of the 118 screening reports that recommended a full report, 50% were followed up by the prosecution authorities. In contrast, non-recommendation of a full report was almost always followed, while 16% of open recommendations resulted in a full report. Instigation of a full report was significantly associated with major crimes, and with positive recommendation compared to open recommendation. The concordance between screening and full reports was 46% regarding psychosis, 78% regarding unconsciousness, and 94% regarding mental retardation. Based on these findings, the value of the system of screening reports seems to lie primarily in negative recommendations. Low concordance between screening and full reports, and the limited follow-up of expert recommendations for full reports, indicate that the system has questionable validity. Keywords: Forensic psychology and psychiatry, screening forensic reports, full forensic reports, forensic experts, quality assurance, court reports Correspondence: Pål Grøndahl, Centre for Research and Education in Forensic Psychiatry, Ullevål University Hospital, University of Oslo, Sognsvannsveien 21, N-0320 Oslo, Norway. E-mail: pagron@kompetanse-senteret.no ISSN 1478-9949 print/issn 1478-9957 online ª 2007 Taylor & Francis DOI: 10.1080/14789940701441094 Paper II - Page 1 of 11
332 P. Grøndahl et al. Introduction The primary task of forensic psychiatric and psychological experts is to assist the courts in determining the defendant s accountability at the time of the crime, and eventually to give an assessment as to the likelihood of re-offence by the defendant. Some countries have implemented a system in which a forensic psychiatric screening report ( minor report ) can be requested by the prosecution authorities. 1 In Norway such a report is produced by a forensic expert based on police documents and one interview with the defendant. The screening report concludes with one of three alternative recommendations as regards drawing up a full report: recommended, not recommended, or left undecided. The screening report is considered to be expert advice for the prosecution authorities, which are free to follow or discard the conclusion of the screening report regarding a full report. The screening report by itself is normally not a document valid for the court. The legal basis for the system of screening reports is found in the Norwegian Criminal Procedure Act (x165), which states that both the prosecution authorities and the defence council can request a screening report. The report presents a forensic expert evaluation of two matters. First, the report clarifies whether the defendant had a mental state relevant to x44 of the Norwegian Criminal Act: x44 states that a person who at the time of the crime was in a state of psychosis, had a high grade of amnesia/unconsciousness, or had severe mental retardation (IQ 5 55) cannot be punished. Note that the circumstances of the crime do not count, and Norway thus is one of the very few countries that follow the biological principle only the mental state is decisive in issues of accountability. Second, the screening report makes a recommendation concerning the need for a full report. The Norwegian Criminal Act does not ask for identification of any mental disorder in the defendant only whether the defendant has one of the three mental states given in x44. Screening and full reports have many common features. They both draw conclusions regarding the mental state of the defendant in relation to accountability according to x44, and both provide recommendations to the legal system as to how to proceed with the defendant. However, they differ in some respects. See Table I. To the best of our knowledge, no studies have been published to date of screening reports or their purpose in the legal system. A literature search in Medline, PsychInfo, Embase, and SveMedþ did not find any relevant papers. A study of this kind could provide important empirically-grounded feedback to the Norwegian legal system, and could also to some extent Paper II - Page 2 of 11
Table I. Contents of screening reports and full reports. Psychiatric screening reports 333 Content Screening reports Full reports Background info/police documents Yes Yes Info from third party Sometimes Yes Anamnesis/interview Yes Yes Profession of the experts Psychiatrists/psychologists Psychiatrists/psychologists No. of experts 1 2 No. of examinations of defendant 1 2 Setting Prison, institution, or expert s office Prison, institution, or expert s office Testing No Yes ICD-10 diagnosis No Yes Conclusion: psychosis Yes Yes Conclusion: unconsciousness Yes Yes Conclusion: mental retardation Yes Yes reduce experts concerns about missing or limited control over the process and outcome of their professional work (Strasburger, Miller, Commons, Gutheil, & LaLlave, 2003). Additionally, research regarding the quality and thoroughness of forensic reports can be viewed as necessary for quality assurance in the forensic field (Wettstein, 2005). Aims of the study Because both screening and full forensic psychiatric reports are of importance to the legal process, it will be of considerable relevance to study them systematically, and to research some pertinent questions. Are screening reports considered relevant by the prosecution authorities? To what extent are their recommendations followed? What is the concordance of the conclusions of the screening reports and the full reports concerning the state of psychosis, amnesia/unconsciousness, or severe mental retardation? The aim of this paper is to investigate these issues and to give an empirically-based evaluation of the screening report system. Methods Material The data for this study consisted of all 419 screening reports issued by the Oslo Police District s Office for Forensic Psychiatry from January 1, 2002, to May 31, 2005. 2 Additionally, all the 91 (22%) full reports issued from this set of 419 screening reports were collected from the files of the Norwegian Forensic Board. 3 Paper II - Page 3 of 11
334 P. Grøndahl et al. Rating form All reports were assessed using a form developed by the first and second authors. The form consisted of 33 variables for the screening reports and 17 for the full reports, making a total of 50 variables. Information rated from the screening reports included: demographic data on the defendant (age, sex, work employment, partner relation, earlier psychiatric/psychological treatment), type of charged crime, and ICD-10 diagnosis (for internal use only). The recommendations of the screening reports were noted. The presence of psychosis, unconsciousness, or severe mental retardation (IQ 5 55) was considered. The additional 17 variables that the full reports were rated on were mostly identical to those of the screening reports. The concordance of the two reports conclusions concerning psychosis, unconsciousness, or severe mental retardation was calculated. Information regarding how the recommendations in the screening reports were used by the principals was collected from the Norwegian Criminal Register, independent of the rating form. We recorded whether the recommendations of the screening reports were followed, whether the case was dismissed (and the reason for this, e.g., doubt concerning the defendant s accountability, etc.), and whether the defendant was sentenced. Rating procedure The authors PG and SI rated all the reports. During the period under study, a total of six forensic experts worked at the Office for Forensic Psychiatry. The two raters had themselves issued several of the screening reports: if one of the raters had issued a particular report, the other rater would rate that report in order to avoid bias. The reports issued by the other experts were randomly distributed between the raters. The ratings were carried out in two stages: first all the screening reports were rated, and then all the full ones. In order to examine inter-rater reliability, the two raters (PG and SI) both scored the same 30 screening reports on key variables such as presence of psychosis, unconsciousness, or severe mental retardation, and on the main conclusions (positive, negative, or open). Statistics Analyses were carried out using SPSS 14.0. Inter-rater reliability was estimated using kappa statistics. Categorical data were analysed using chisquare, and continuous data with independent sample t tests. Associations between relevant independent variables and the initiation of a full report (dependent variable) were examined by logistic regression analyses. The strengths of these associations were expressed as odds ratios (ORs) with Paper II - Page 4 of 11
Psychiatric screening reports 335 95% confidence intervals (CI). A significance level of p 5.05 was chosen, and all tests were two-tailed. Ethics The study was approved by the Regional Committee for Research Ethics of Health Region East, the National Data Inspectorate, and the Directorate of Public Prosecution. These official bodies were in agreement that the defendants should not be informed about the use of reports for this study. Results Inter-rater reliability There was complete agreement between raters concerning the presence or not of unconsciousness and mental retardation in the 30 screening reports scored by both. Agreement regarding psychosis was kappa.88 (95% CI.71 1.00). Agreement regarding the main conclusion of the screening reports was kappa.56 (95% CI.33.78). Early in the process, the raters discovered that their low agreement concerning main conclusions was due to their different views about whether a conclusion was actually stated. As a consequence, the raters decided that from that point only explicit recommendations would be rated as a positive or negative conclusion. If no explicit statement was given, the report would be rated as giving an open recommendation. Characteristics of defendants who only had screening reports The severity of the alleged crime was the variable that made a significant difference between those who had only a screening report and no full report, and those who went on to a full report. The prosecution authorities or defence requested a full report for those defendants charged with more severe crimes (for example homicide or attempted homicide) than those who did not have such a request (see Table II). In addition, those who also had full reports were younger (p ¼.006), and their civil status was more frequently non-paired or not registered ( p ¼.01). Variables associated with request for a full report In univariate regression analyses, age, positive recommendation (with open recommendation as reference), and severity of crime were significantly associated with request for a full report (Table III). However, only positive recommendation and severity of crime were significantly associated with full report in the multivariate analysis. Paper II - Page 5 of 11
336 P. Grøndahl et al. Table II. Characteristics of the sample in relation to screening and major reports. Variable Screening and full report (n ¼ 91) Screening report only (n ¼ 328) p Total (n ¼ 419) Age, mean (SD) 32.4 (9.8) 35.8 (10.7).006 35.1 (10.6) Gender, n (%).27 Male 83 (91) 285 (87) 368 (88) Female 8 (9) 43 (13) 51 (12) Country of birth, n (%).78 Norway 60 (66) 211 (64) 271 (65) Other countries 31 (34) 117 (36) 148 (35) Level of education, n (%).46 9 years 28 (31) 86 (26) 114 (27) 10 12 years 23 (25) 95 (29) 118 (28) 13 years 14 (15) 65 (20) 79 (19) Not registered 26 (29) 82 (25) 108 (26) Civil status, n (%).01 Paired relation 23 (26) 90 (28) 113 (27) Non-paired 47 (52) 204 (62) 251 (60) Not registered 21 (22) 34 (10) 55 (13) Paid work 16 (18) 72 (22).36 88 (21) Former screening report, n (%) 18 (20) 43 (13).09 61 (15) Psychiatric treatment, n (%).24 None 18 (20) 82 (25) 100 (24) Outpatient 14 (16) 67 (20) 81 (19) Hospitalized 53 (58) 162 (50) 215 (52) Not registered 4 (4) 15 (5) 19 (5) Charged crime, n (%) 5.001 Homicide or attempted 20 (22) 20 (6) 40 (10) Other violent crimes 28 (31) 119 (36) 147 (35) Other serious crimes 34 (37) 103 (32) 137 (33) Other crimes 9 (10) 85 (26) 94 (22) How did the prosecutors deal with the recommendations in the screening reports? Of the 118 reports with a positive recommendation for a full report, 50% lead to a full report. Thus in 59 cases, a positive recommendation for a full report was not followed. Of these 59 cases, 20 were dismissed due to doubt regarding the defendant s accountability, 7 were sentenced, and 32 had not been closed by the time of our study. If the recommendation in the screening report was negative, this advice was followed in 98% of the cases. Of the 181 screening reports with an open recommendation, 16% were followed by a full report (see Table IV). Paper II - Page 6 of 11
Psychiatric screening reports 337 Table III. Associations between independent variables and the request for a full report (with no full report as reference), according to logistic regression analyses. Univariate Multivariate OR 95% CI p OR 95% CI p Age 0.97 0.95 0.99.007 0.99 0.97 1.02.50 Civil status Paired (reference) 1.00 Single 0.66 0.42 1.06.09 Recommendation Open (reference) 1.00 1.00 Negative 0.13 0.04 0.45.001 0.15 0.04 0.49.002 Positive 5.24 3.07 8.96 5.001 4.38 2.51 7.65 5.001 Former observation No (reference) 1.00 Yes 1.70 0.92 3.12.09 Crime Other crime (reference) 1.00 Homicide/attempted 9.44 1.00 23.83 5.001 4.19 1.52 11.51.006 Other violent crime 2.22 1.46 4.95.05 1.80 0.76 4.28.18 Other serious crime 3.12 1.42 6.86.005 2.41 1.03 5.62.04 Table IV. Prosecutors responses to the recommendations of the screening reports. Variables Full report Full report not requested (n ¼ 91) requested (n ¼ 328) n (%) n (%) Screening report conclusion Full report recommended 59 (65) 59 (18) 5.001 Full report not recommended 3 (3) 117 (36) 5.001 Open recommendation 29 (32) 152 (46).01 Fate of full recommended 59 (100) Case dismissed* 20 (34) Other reasons 7 (12) No information/case still open 32 (54) Fate of full not recommended 3 Case dismissed* 1 Other reasons 0 No information/case still open 2 Fate of open recommendation 29 152 Case dismissed* 13 58 Sentenced 7 63 No information/case still open 9 31 p *Dismissed due to doubt regarding defendant s accountability (code 065 in the criminal register). Paper II - Page 7 of 11
338 P. Grøndahl et al. Concordance between reports concerning non-culpability The total agreement between screening and full reports concerning psychosis was 46%, kappa.25. In 33 of the screening reports the conclusion was doubt concerning psychosis, while only one full report expressed doubt. There was a high level of agreement (24 cases out of 89) among the reports with negative conclusions that is, the reports that concluded there was no psychosis. None of the screening reports with negative conclusions concerning psychosis were overruled by the full reports. However, 10 of the screening reports which came to a positive conclusion regarding psychosis were not borne out by the full reports, which were negative for psychosis (see Table V). We calculated kappa statistics for the concordance of the screening and full reports regarding ICD-10 diagnoses which could imply psychosis (i.e., F00 09, F10 19, F20 29, and F30 39). Kappa values for F00 09 could not be calculated due to low numbers; for F10 19 kappa was.54, for F20 29 it was.47, and for F30 39 it was.13. For decisions regarding unconsciousness, agreement between screening and full reports was 78%. This agreement arose mainly through negative conclusions, since the diagnosis was uncommon. Again, screening reports Table V. Concordance of main conclusions in screening and full reports. Screening reports Major reports Yes No Doubt Total Psychosis Yes 16 10 0 26 No 0 24 0 24 Doubt 5 33 1 39 Total 21 67 1 89 Agreement 46%, kappa.25 Unconsciousness Yes 0 1 0 1 No 0 69 0 69 Doubt 2 16 0 18 Total 2 86 0 88 Agreement 78%, kappa not applicable Severe mental retardation Yes 0 0 0 0 No 1 80 0 81 Doubt 0 4 0 4 Total 1 84 0 85 Agreement 94%, kappa not applicable Paper II - Page 8 of 11
Psychiatric screening reports 339 expressed doubt about unconsciousness (18 cases), in contrast to the full reports. Agreement between reports over decisions concerning severe mental retardation was 94%. Discussion This study explored the Norwegian system of screening forensic psychiatric reports. It has asked whether these screening reports are considered relevant by the prosecution authorities, and to what extent their recommendations are followed. Finally, correspondence between the conclusions of the screening reports and of the full reports has been assessed. We found that the recommendations of the screening reports made a significant difference to prosecutors decisions. Negative recommendations were almost always followed, while only half of the positive and 16% of the open recommendations lead to a full report. The severity of the crime was a strong predictor of full report, and so was a positive recommendation for a full report (with open recommendation as reference). Agreement between screening and full reports regarding psychosis was low, but agreement was high regarding both unconsciousness and severe mental retardation, although these states were rare. Inter-rater agreement on the main conclusions (recommendations) in the screening reports was kappa.56; following this finding the rating procedure was changed. We did not recalculate kappa following the procedure change, so this kappa value is artificially low. There are no other published studies to which our findings can be compared. Nevertheless, our study raises several questions regarding the Norwegian system of screening reports. First, it seems that the prosecution authorities dismiss a lot of recommended cases, due to doubt concerning defendant culpability. It is debatable whether important legal decisions with considerable consequences for defendants can be made on the basis of provisional reports. This practice could also give the experts who issue screening reports a feeling of futility, since their positive recommendations are frequently put aside. Second, the validity of the screening reports could be questioned, since their agreement with the full reports was quite low as regards psychosis. However, the correct classification of affective disorders in general has low reliability. One factor might lessen this concern: no negative screening conclusion regarding psychosis was overruled into a positive conclusion in a full report. This may imply that there were few false positive diagnoses of psychosis in the screening reports, when the full reports are used as a gold standard. Paper II - Page 9 of 11
340 P. Grøndahl et al. A more general concern regarding the identification of psychosis in forensic psychiatric practices emerges at this point, when we find that agreement between two independent experts (i.e., those producing the screening reports and those producing the full reports) is, seemingly, low. The main tool for the forensic expert is the clinical interview (Grøndahl, 2005). It could be argued that the clinical interview is not a sufficient tool to achieve acceptable reliability among experts. This seems to be the case, despite the fact that the task of the expert is to identify defendants with a distinct or apparent psychosis in accordance with penal law. Third, the seriousness of the criminal act was the main characteristic to prompt the prosecuting authorities to initiate a full report. In this regard Norway seems to follow a European tradition (Soothill et al., 1983). A serious criminal act may, if the defendant is found guilty, trigger a harsh sentence. It seems logical therefore to initiate a full report in serious criminal cases in order to examine the defendant s accountability thoroughly, thereby protecting the interests of justice. However, there is a risk of false negatives when one primarily focuses on the crime and possibly overlooks the behaviour of the defendant in prison or in court. Initiation of a full report seems to be less likely if the crime is minor (shoplifting, small theft, threats, etc.). This may lead to miscarriages of justice. Fourth, 181 of the screening reports made open recommendations (i.e., not explicitly positive or negative). This type of conclusion may not be very helpful for the principals, and it could be argued that the practice here should be changed. However, we must take into consideration that this study is based on a sample from the Office for Forensic Psychiatry only. We do not know whether this is representative of practice elsewhere in Norway. On the other hand, the Office issues many screening reports, which comprise a considerable proportion of all such reports made in Norway. To conclude: this study indicates that there is uncertainty about the purpose of screening reports in the Norwegian penal system. Screening reports should address doubt about a defendant s accountability and clarify whether there is a need for a full report. However, the system seems to work most effectively when the conclusion is no need for a full report. Whether the use of screening reports is cost-effective is not known; there are no general statistics about their use. We would, therefore, strongly recommend more statistical information to be collected by the criminal registers about the use of screening reports (as practiced in Sweden). In this way, knowledge could be built up about the effects of screening reports in the Norwegian penal system. The findings of this study should also encourage more studies of concordance between experts carrying out forensic examinations. This would hopefully increase both the quality of such examinations and their scientific basis. Paper II - Page 10 of 11
Psychiatric screening reports 341 Limitations and strengths Only the screening reports issued by Oslo Police District s Office for Forensic Psychiatry were assessed. It would be of interest to obtain data about screening reports issued by experts in other parts of the country. The screening reports were scored by individuals who themselves had issued several of the reports. Despite our attempt to avoid bias by not scoring reports we ourselves had issued, we cannot be completely certain that no biases have occurred. One of the strengths of our study is the considerable sample size, which provides good statistical power for the analyses performed. In the Norwegian system, every citizen has a personal identity number and the criminal registers are of very high quality, so we are confident that we identified all major reports issued. Acknowledgements Thanks to the Norwegian Forensic Board, Professor Petter Laake of the University of Oslo, and Turid A. Nordby of the Oslo Police for their helpful support. Pål Grøndahl received research grants for this project from the Norwegian Foundation for Health and Rehabilitation and from the Centre for Research and Education in Forensic Psychiatry, Ullevål University Hospital. Notes 1 Norway and Sweden (x7 reports) are seemingly the only countries which have employed a systematic use of screening reports. 2 Originally 424, but five outliers on age was excluded from the analysis. 3 It is mandatory that all major reports are sent to this commission for approval of its quality and conclusions. References Grøndahl, P. (2005). Scandinavian forensic psychiatric practices: An overview and evaluation. Nordic Journal of Psychiatry, 59, 92 102. Soothill, K. L., Adserballe, H., Bernheim, J., Dasananjali, T., Harding, T. W., Thomaz, T., et al. (1983). Psychiatric reports requested by the courts in six countries. Medicine, Science, and the Law, 23, 231 241. Strasburger, L. H., Miller, P. M., Commons, M. L., Gutheil, T. G., & LaLlave, J. (2003). Stress and the forensic psychiatrist: A pilot study. Journal of the American Academy of Psychiatry and the Law, 31, 18 26. Wettstein, R. M. (2005). Quality and quality improvement in forensic mental health evaluations. Journal of the American Academy of Psychiatry and the Law, 33, 158 175. Paper II - Page 11 of 11