More symptoms, less crime: distinguishing clinical severity from violence risk in a national follow-up study of adolescent forensic inpatients

BACKGROUND: The predictive value of symptom severity on post-discharge criminal offending in forensic psychiatric settings remains unknown, potentially leading to prolonged institutionalization of stabilized patients under the rationale of public safety. Furthermore, outcomes of adolescent forensic psychiatric inpatient care are understudied. AIMS: To explore if clinical symptom severity predicts subsequent criminal offending, to investigate the role of severe disorders in future offending, and to quantify offence rates among former adolescent forensic inpatients compared to the general population. METHODS: This national register-based study followed 289 youths (under 18 years) consecutively admitted to a forensic psychiatric inpatient unit in Finland between 2003 and 2019 for up to 18 years. Offence rates were analyzed using Cox proportional hazards regression, comparing patients against 1,149 matched general population controls. Predictors included the Brief Psychiatric Rating Scale (BPRS; score range 18-126 points) and Structured Assessment of Violence Risk in Youth (SAVRY), both assigned during a two-month evaluation. RESULTS: Former patients had a significantly higher hazard of offending than controls (HR 6.67, 95% CI 5.10-8.72). However, higher clinical symptom severity (BPRS) independently reduced the risk of future offending by 2% per point (HR = 0.98, 95% CI 0.96-1.00, p = .025); e.g., a 20-point difference corresponds to an approximate 34% reduction in risk. High-risk patients (SAVRY) with severe symptoms offended at rates similar to low-risk patients. Personality disorders were associated with subsequent offending (HR = 1.92, 95% CI 1.01-3.66, p = .047), while schizophrenia spectrum disorders and Length of Stay were not. CONCLUSIONS: Severe psychopathology predicts reduced subsequent offending after forensic adolescent inpatient care, possibly due to treatment responsiveness, systemic safety nets and functional impairment. Prolonging hospitalization under the rationale of public safety based on symptom severity may be unnecessary for stabilized patients if continuity of care and outpatient supervision are ensured.