The Time Before the Crime: Risk Patterns in Individuals Who Commit Criminal Acts and Undergo a Forensic Psychiatric Evaluation
Conditions: Crime
Sponsor: Karolinska Institutet

Date: 2025-08-31 
Unique Protocol ID: 2024-07566-01 
Title: The Time Before the Crime - Risk Patterns in Offenders Undergoing a Forensic Psychiatric 
Evaluation (Tibec) 
Principal Investigator: Katarina Howner, Associate professor, Karolinska Institutet 
 
 

Review Template for Medical Record Review 
 
Case Number (anonymized):  
 
Gender: ☐ Male ☐ Female 
 
Age at Index Offense:  
 
Age group: ☐ 18-24 years ☐ 25-39 years  ☐ ≥ 40 years 
 
Unit(s) Reviewed:  
 
☐ Outpatient only ☐ Inpatient only ☐ Emergency department only ☐ Multiple units 
 
Review Period:  
 
Review Performed By:  
 
 
Markers 
Marker 
 
Inpatient (IP) 
Outpatient (OP) 
Emergency (ED) 
Benzodiazepines or 
benzodiazepine-like 
medications 
☐ 
☐ 
☐ 
Central stimulant 
medications 
☐ 
☐ 
☐ 
Lack of 
treatment/intervention 
☐ 
☐ 
☐ 
Non-adherence to 
treatment/intervention 
☐ 
☐ 
☐ 
Compulsory psychiatric 
care 
☐ 
☐ 
☐ 
Coercive measures     
☐ 
☐ 
☐ 
Absence of violence 
risk assessment 
☐ 
☐ 
☐ 
Increased psychiatric 
care needs 
☐ 
☐ 
☐ 
Parallel psychiatric care 
contacts 
☐ 
☐ 
☐ 
Polypharmacy (≥ 5 
psychiatric meds) 
☐ 
☐ 
☐ 
Weapon possession or 
interest 
☐ 
☐ 
☐ 

Firearm unsuitability 
report 
☐ 
☐ 
☐ 
Suicide attempt 
☐ 
☐ 
☐ 
Historical suicide 
attempt 
☐ 
☐ 
☐ 
Aggression or violence 
☐ 
☐ 
☐ 
History of aggression or 
violence 
☐ 
☐ 
☐ 
Missed healthcare 
appointment 
☐ 
☐ 
☐ 
Missed appointment 
without follow-up 
☐ 
☐ 
☐ 
Multiple psychiatric 
diagnoses 
☐ 
☐ 
☐ 
Safeguarding concern 
report 
☐ 
☐ 
☐ 
Police transport to care 
☐ 
☐ 
☐ 
Substance use 
(excluding alcohol) 
☐ 
☐ 
☐ 
Alcohol use 
☐ 
☐ 
☐ 
Negative life event 
☐ 
☐ 
☐ 
Social vulnerability 
☐ 
☐ 
☐ 
Absence of crisis plan 
☐ 
☐ 
☐ 
 
IP = Inpatient care, OP = Outpatient care, ED = Emergency department 
 
 

List of Markers with Definitions 
 
Benzodiazepines or benzodiazepine-like medications 
Definition: The marker is considered positive if the patient was prescribed or administered a 
benzodiazepine or a benzodiazepine-like medication during the review period. 
 
Note: Benzodiazepine-like medications refer to the substances Zopiclone and Zolpidem 
 
Central stimulant medications 
Definition: The marker is considered positive if the patient was prescribed or administered 
central stimulant medications during the review period. 
 
Lack of treatment/intervention 
Definition: The marker is considered positive if the patient had no treatment or intervention 
prescribed for their (main) diagnosis during the review period. 
 
Note: Treatment refers to psychological or pharmacological treatment. Intervention refers to 
actions addressing issues resulting from diagnoses that do not primarily require pharmacological 
or psychological treatment (such as autism or intellectual disability), e.g., municipal housing, 
services under the LSS Act, or legal guardian. 
 
If the patient lacks a main diagnosis, the diagnosis made at, e.g., an emergency visit is 
considered. 
 
Non-adherence to treatment/intervention 
Definition: The marker is considered positive if the patient was prescribed treatment or 
intervention but showed non-adherence during the review period. 
 
Note: Non-adherence includes missed injections, low drug levels, failure to take medication, 
missed therapy appointments, not collecting medication from the pharmacy, or not residing in 
designated housing. 
 

Compulsory psychiatric care 
Definition: The marker is considered positive if the patient was treated under the Compulsory 
Psychiatric Care Act or the Forensic Psychiatric Care Act at least once during the review period. 
 
Note: It is also positive if a medical certificate about compulsory care was issued and a 
detention decision was made, even if no final commitment decision followed. 
 
Coercive measures 
Definition: The marker is considered positive if the patient was subject to coercive measures 
decided by the chief physician under the Compulsory Psychiatric Care Act or the Forensic 
Psychiatric Care Act during the review period. 
 
Absence of violence risk assessment 
Definition: The marker is considered positive if no documented violence risk assessment was 
made during psychiatric care visits within the review period. 
 
Note: If an assessment exists, the marker is negative regardless of quality or risk rating. 
 
Increased psychiatric care needs 
Definition: The marker is positive if the patient had any of the following during the review 
period: 
a) ≥2 inpatient admissions, 
b) ≥1 readmission within one week after discharge, 
c) ≥2 emergency visits, 
d) ≥1 inpatient stay lasting over two months. 
 
Parallel psychiatric care contacts 
Definition: The marker is considered positive if the patient had parallel psychiatric care contacts 
with both general psychiatry and specialized addiction services. 
 
Note: Includes outpatient visits, inpatient admissions, or emergency visits. Excludes municipal 
addiction care. 
 

Polypharmacy (≥ 5 psychiatric medications) 
Definition: The marker is positive if the patient was prescribed ≥5 psychiatric medications at any 
point during the review period. 
 
Note: Includes medications for psychiatric symptoms and narcotic substances like opioids and 
Pregabalin, both regular and PRN (when required). 
 
Weapon possession or interest 
Definition: The marker is considered positive if the patient had access to weapons, carried a 
weapon during a search, or expressed current or historical interest in weapons during the 
review period. 
 
Note: Weapons refer to firearms or knives. 
 
Firearm unsuitability report 
Definition: The marker is considered positive if a report was filed with the police during the 
review period regarding the patient's unsuitability to possess firearms, in accordance with 
Chapter 6, Section 6 of the Swedish Firearms Act (1996:67). 
 
Suicide attempt 
Definition: The marker is considered positive if the patient attempted suicide at least once 
during the review period. 
 
Note: Includes all acts intended to end life. If intent is denied or unclear, it is still considered 
positive if the event required medical care. 
 
Historical suicide attempt 
Definition: The marker is considered positive if there is information indicating the patient 
attempted suicide at least once before the review period. 
 
Note: Includes all acts intended to end life. If intent is denied or unclear, it is still considered 
positive if the event required medical care. 
 

Aggression or violence 
Definition: The marker is considered positive if the patient displayed aggressive or violent 
behavior toward objects, others, or self during the review period. 
 
Note: Behavior must be documented as a clinical observation or from history. Includes all types 
of self-harm, e.g., cutting.  
 
History of aggression or violence 
Definition: The marker is considered positive if there is information indicating the patient had 
shown aggressive or violent behavior before the review period. 
 
Note: Behavior must be documented as a clinical observation or from history. Includes all types 
of self-harm, e.g., cutting. 
 
Missed healthcare appointment 
Definition: The marker is considered positive if the patient missed or canceled at least one 
scheduled healthcare appointment during the review period. 
 
Missed appointment without follow-up 
Definition: The marker is considered positive if the patient missed or canceled at least one 
appointment during the review period without adequate follow-up by the healthcare provider. 
 
Note: Adequate follow-up includes phone contact, home visits, or rescheduling. 
 
Multiple psychiatric diagnoses 
Definition: The marker is considered positive if the patient had psychiatric diagnoses from three 
or more different diagnostic clusters during the review period. Diagnoses must be recorded 
using ICD codes. 
 
Note: Clusters are based on the first number following the F in ICD codes. For example, F20.3 
and F29.9 are in the same cluster. An example of three different clusters: F20.0 (schizophrenia), 
F10.0 (alcohol intoxication), F84.1 (autism). 
 

Safeguarding concern report 
Definition: The marker is considered positive if a family member or other person reported a 
concern about the patient's mental state to psychiatry, or if a report was made to social services 
in accordance with Chapter 14, Section 1 of the Social Services Act (2001:453). 
 
Police transport to care 
Definition: The marker is considered positive if the patient arrived at psychiatric care with police 
assistance during the review period, either: 
a) voluntarily, 
b) under Section 11 of the Police Act (1984:387), 
c) under the Care of Intoxicated Persons Act (1976:511), or 
d) under Section 47 of the Compulsory Psychiatric Care Act (1991:1128). 
 
Substance use (excluding alcohol) 
Definition: The marker is positive if the patient during the review period: 
a) had ≥1 substance use diagnosis, 
b) self-reported use, 
c) tested positive for non-prescribed narcotics, 
d) was reported to social services under the Care of Substance Abusers Act (1988:870), or 
e) was assessed by a physician according, Section 9 of the Care of Substance Abusers Act 
(1988:870). 
 
Note: Alcohol use is excluded from this marker. 
 
Alcohol use 
Definition: The marker is positive if the patient during the review period: 
a) had ≥1 alcohol-related diagnosis, 
b) self-reported overuse, 
c) had >0.30 µmol/L phosphatidylethanol, 
d) was reported to social services under the Care of Substance Abusers Act (1988:870), or 
e) was assessed by a physician according, Section 9 of the Care of Substance Abusers Act 
(1988:870). 
 
Note: This marker refers solely to alcohol use or dependence. 
 

Negative life event 
Definition: The marker is considered positive if the patient experienced a negative life event 
(e.g., separation, bereavement, unemployment, or housing loss) during the review period and 
psychiatry was informed. 
 
Social vulnerability 
Definition: The marker is considered positive if the patient was in a socially vulnerable situation 
that significantly affected functioning during the review period. 
 
Examples: lack of social network, homelessness, or no source of income. 
 
Absence of crisis plan 
Definition: The marker is considered positive if there was no crisis plan in the patient’s record 
during the 12 months preceding the index offense date. 
 
Note: This refers to the full year before the offense, not just the 3-month review period. The 
marker is positive only if the plan is entirely missing or older than 12 months.