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Aims To quantify the relationship between alcohol and violence with increasing age. Methods Data were from The National Longitudinal Study of Adolescent to Adult Health (ADD Health) of 20,386 people representative of the US population. Mean age at the first wave of interviews was 16.2 years, with subsequent interviews mean of 1, 6.3 and 12.9 years later. We used random-effects models and predictive marginal effects of the association between varying quantities of alcohol consumption and violence while controlling for possible confounders. Results Violence was reported by 19.1% of participants at wave I but just 2.1% at wave IV. The random-effects model showed that consuming 1–4 drinks on each occasion was associated with a modest increase in risk of violence in both males (odds ratio (OR) 1.36, 95% CI 1.13–1.63) and females (OR 1.33, 95% CI 1.03–1.72). For consumption of five or more drinks on each occasion, the risk remained similar for females (OR 1.40 (0.99–1.97)) but increased considerably for males (OR 2.41 (1.96–2.95)). Predictive marginal effects models confirmed that violence rates decreased with age. Conclusions Alcohol is most strongly linked to violence among adolescents, so programmes for primary prevention of alcohol-related violence are best targeted towards this age group, particularly males who engage in heavy episodic drinking.

Background and aimReducing alcohol misuse by male prisoners is an important global issue. Control of drinking behaviour could be a useful target for intervention in this population and locus of control could be a causal factor in this. We aimed to assess the effect of a clinical psychologist‐facilitated group intervention on male prisoners’ locus of control of drinking behaviour.DesignA two‐arm, single‐site, open, randomised controlled trial.SettingA category B, local training prison in South Wales, housing nearly 800 mostly sentenced men.ParticipantsPrisoners serving under two years who met inclusion criteria for pre‐imprisonment alcohol misuse, alone or with drug misuse. A total of 119 were allocated to the intervention arm and 119 to the control arm; 104 and 87 respectively completed the post‐randomisation baseline interview and 68 and 60 completed a second interview about 4 weeks later, respectively after intervention or treatment as usual (TAU) alone.InterventionNine clinical psychologist‐facilitated groups in the prison over three weeks. Range of participants per session was 1‐7, with 3‐5 most usual.MeasuresThe primary outcome was Locus of Control of Behaviour (LCB); secondary outcomes included mental state generally (Comprehensive Psychiatric Rating Scale/CPRS) and specifically (Beck Depression Inventory/BDI). An integral process evaluation was conducted.FindingsLCB scores decreased during the study, but without significant intervention effect (‐1.7 (95% CI ‐5.2 to 1.8), p=0.334). Change among completers in the control group was from a mean score of 37.4 (standard deviation [SD] 10.0) to 33.7 (SD 11.7) and in the intervention group from 37.4 (11.6) to 31.9 (11.8). Secondary outcomes, including change in mental state, did not differ between arms, but 686 (64%) sessions were lost, most because of ‘prison issues’.ConclusionsA clinical psychologist‐facilitated group intervention did not have a statistically significant effect on sense of control of drinking behaviour among men with pre‐imprisonment alcohol misuse serving under two years in a South Wales prison. The study proved coterminous, however, with 40% prison staff cuts which seem likely to have contributed to the high loss of group sessions and possibly overwhelmed any treatment effect. Intervention completion failures, previously cited as harmful, had no effect here, so the trial should be repeated when prison climate improves.

Background Most secure psychiatric hospital patients are of childbearing age, but their parental status is minimally researched. Aim The aim of the study is to describe the parent patients in one regional secure hospital and explore post-admission child–parent contact. Methods A 9-year records survey of a complete secure hospital admissions cohort was conducted. Results Nearly half of the cohort of 165 patients (46%) were parents. Parent patients were less likely than childless patients to have diagnostic co-morbidity or to have received childhood mental health care but were more likely to have committed a homicide/life-threatening index offence with family or friend victims. Men, whether fathers or not, and childless women were unlikely ever to have harmed a child, but it was more likely than not that mother patients had. Records indicated minimal discussion about childlessness. Ninety-four (60%) of the 157 children involved were under 18 years on parental admission. Adult children who had been living with the parent patient before the parent's admission invariably maintained contact with them afterwards, but nearly half (48%) of such under 18-year-olds lost all contact. The only characteristic related to such loss was the index offence victim having been a nuclear family member. Conclusions As the discrepancy in whether or not parent patients and their children continued contact with each other after the parent's admission seemed to depend mainly on the child's age and his or her resultant freedom to choose, acquisition of accurate data about affected children's perspective on visiting seems essential. Given that parent patients had experienced relative stability in interpersonal relationships and had rarely had childhood disorders, parenting support in conjunction with treatment seems appropriate. Copyright © 2017 John Wiley & Sons, Ltd.

Forensic psychiatry and psychology in Europe place emphasis on clinical service delivery and the treatment of offenders with mental disorder while also working at all levels alongside the criminal justice system and other agencies. In this chapter, we first consider the various roles taken by forensic psychiatrists and, to an extent, other clinicians in the field. Secondly, we discuss the special impact of the psychologist on evaluation, management, and interventions, with support through systematic assessments and reproducable measurement of risk and change. Thirdly, we take the practitioner-expert witness tension as an example of the potential conflicts between the various roles which forensic psychiatrists and clinical psychologists must adopt, and how these may be resolved. Although these roles are strictly separated in some countries, decisions on how to act are not evidence-based, and it is arguable that the most important resolution lies in clarity for all parties on the nature and extent of roles and relationships. We go on to show that, even within an inquisitorial approach, there needs to be no strict separation between evaluation for legal purposes and therapy, using the Belgian social defense system as an illustration of this.

AIMS: To disentangle the alcohol-related needs of short stay, revolving door, male prisoners, and offer a theoretically driven but practical approach for allocation of scarce service resources. METHODS: A prospective longitudinal interview, questionnaire and records study of pre-trial men newly imprisoned in Wales and SW England. RESULTS: Two hundred and forty-one pre-trial men completed an interview and questionnaires within a week of a new reception into prison; 170 completed follow-up 3 weeks later. Questions about problems with alcohol or illicit drugs revealed that problem drinkers were less likely than problem drug users to recognize their difficulty or seek or get help for this during their first month of imprisonment. Co-morbidity was common, but a third of the men had alcohol problems alone. Use of the Alcohol Use Disorders Identification Test (AUDIT) questionnaire identified 80% (195/241) men likely to require some intervention, twice the number identified by direct questions relying on prisoners' judgment about problem use. Furthermore it allowed categorization according to likely risk (dependency), need (problem recognition) and responsivity (wish for help). CONCLUSION: Alcohol misuse is recognized, worldwide, as fuelling crime and more common among prisoners than the general population. In England and Wales, it is a particular factor in brief but recurrent periods of imprisonment. There have been calls to pay more attention to its use in this context, albeit without any increase in resources. Adding two questions to standard screening enables application of the risk-need-responsivity model to problem drinkers and may identify those most likely to benefit from treatment.

Aims and methodThere is evidence that changing diagnoses may be an important factor preceding homicide, but there is little literature on diagnostic antecedents to admission to specialist secure units after violent behaviour. Our aim was to establish the frequency of a history of changing diagnoses in patients in a UK specialist unit, and to explore the characteristics of these patients.ResultsIn total, 38 of 42 study participants had prior contact with psychiatric services. Just over 40% (16 of the 38) had had their diagnosis changed three or more times. All those who had major changes in their diagnosis had received a diagnosis of a psychotic illness at some point prior to the secure unit admission, but then had it withdrawn, only to be restored after prolonged assessment in the secure unit. Personality disorder and substance misuse comorbidity was common in this group; however, non-psychotic diagnoses were seen as more important than psychotic diagnoses by general services.Clinical implicationsChanges in diagnosis between first presentation to psychiatric services and admission to a medium-security unit were more common than would be expected from reports in the general literature. They are a testimony to the difficulties experienced by service providers in delivering a consistent service. This needs to be studied further.

BACKGROUND: International literature is consistent on there being a significant relationship between psychosis and violence, less so on its extent and nature, but two main presentational types are increasingly recognized. In one, people are unremarkable before onset of illness and psychotic symptoms commonly drive violence; in the other, psychosis is preceded by childhood conduct problems, associated with personality disorder, and psychotic symptoms seem less relevant. AIMS: To explore the extent to which variations in aspects of social and service context in different jurisdictions affect presentational type among people admitted to high security hospitals. HYPOTHESES: There will be differences between jurisdictions in proportions of patients with pure psychosis or with psychosis and antecedent personality disorder, but symptom drive to violence will be more common in the pure psychosis group regardless of social, legal and service context. METHOD: Independently conducted record studies were used to compare high security hospital patients with psychosis in Scotland and England, all resident between 25 August 1992 and 13 August 1993. RESULTS: The cohorts were similar in offence histories, predominance of schizophrenia, age at first hospitalization for psychosis and first high security hospitalization. More Scottish patients had co-morbid substance misuse diagnoses and/or personality disorder than patients in England. Psychotic symptom drive to the index offence was, however, four times more likely in the pure psychosis groups, regardless of sex, ethnic group or country. Scottish patients spent less time in high security after the index act. CONCLUSIONS: Our hypotheses were sustained. Knowledge about lifestyle before onset of psychosis is important for interpreting literature on how psychotic symptoms relate to violence. This may also influence longer term outcome, although the shorter length of secure hospital stay in Scotland was perhaps affected more by greater availability of open 'step-down' beds.

Background: Prison suicide rates are high, and suicide-related behaviors (SRBs) higher, but effects of contact with such behaviors in prison have not previously been examined. Aims: To compare the mental state of young men witnessing a peer’s suicide-related behavior in prison with that of men without such experience, and to test for factors associated with morbidity. Method: Forty-six male prisoners (age 16–21 years) reporting contact with another’s suicide-related behavior in prison were interviewed 6 months after the incident, with validated questionnaires, as were 44 without such contact at least 6 months into their imprisonment. Results: Significantly higher levels of psychiatric morbidity and own suicide-related behaviors were found in the witness group, even after controlling for their higher levels of family mental illness and pre-exposure experience of in-prison bullying. Some personal factors were associated with higher morbidity; incident and institutional factors were not. Conclusions: Findings of heightened vulnerabilities among young men exposed to suicide-related behaviors in prison suggest a need for longitudinal study to clarify temporal relationships and inform strategies to prevent or limit development of morbidity and further harm.

Long-term outcome studies may be confounded by change in baseline characteristics over time. Our aims were to compare (1) patients' admission characteristics in six high security hospital discharge cohorts (1984, 1996; 1997–2000) and (2) 5-year outcomes for the first two. The special hospitals' case register was used to identify all discharge and individual admission data. Follow-up data were from multiple records sources. The 1984 and 1996 discharge cohorts were similar in size and admission characteristics, except 1996 had fewer people under the legal category ‘psychopathic disorder’ and more prison transfers, similar to later cohorts. Length of high security hospital stay was similar on discharge in 1984 and 1996, but fewer in 1996 went directly to the community and more to other secure settings. Death rates, and high security returns, were similar. Against prediction, the proportion of people re-convicted was not lower in 1996, despite longer overall in specialist security. Relative over-representatio...

Reliable patient re-conviction data after leaving high security hospitals are of public interest, but official statistics are without context and sometimes incomplete. Some patient sub-groups are rarely studied. Our study describes re-convictions for a complete national annual high security hospital discharge cohort. We hypothesized that: established community living would precede re-conviction and that more people with personality disorder would be re-convicted, with a higher rate, than people with other disorders, even allowing for community time. Cases were identified using the special hospitals' case register; follow-up data were from multiple records sources. Seventy-four patients (38 per cent) were convicted after discharge, 26 per cent of serious offences. All 10 multiple reoffenders (>9 offences) were men. Fourteen per cent of those re-convicted had offended during institutional residence. Median time to first community re-conviction was under two years. Logistic regression analysis confirmed that people with personality disorder were seven times more likely than people with mental illness to be convicted of a serious offence after discharge. Methodological procedures that maximize validity of findings are discussed.

Women offenders constitute a small minority of prisoners in England and Wales, but also the sub-group of prisoners with the fastest growth curve. High rates of mental disorder have been established amongst such women but the extent to which their treatment needs are met is less clear. The aim was to identify and describe women who gain placement in the health service under the Mental Health Act (MHA) 1983 and to compare those under the MHA classifications of ‘psychopathic disorder’ (PD) and ‘mental illness’ (MI). From all new receptions to Holloway Prison – London's prison for pre-trial and sentenced women – between 1st January 1995 and 31st December 1995, those gaining an MHA 1983 disposal were identified. A full record search was done for each woman in this sub-group. Among 3,309 new receptions, only 62 women were transferred from prison to inpatient health services. Full data were available for 26 women under the MHA 1983 category of PD and 34 under MI. The women in the PD group were significantly more likely to have had a history of self-harm and of sexual abuse as a child than women in the MI group, but the PD women remained significantly longer in prison awaiting a hospital bed. It is doubtful whether these women had an adequate response from the health service. Despite manifest need, even among those accepted for in-patient treatment, those with personality disorder appeared disadvantaged compared to those with mental illness. This was a group particularly prone to self-harm, at a time when completed suicide in prison continues to rise. Further research on the specific difficulties in effecting transfer may assist, but it seems likely that there may be a training issue to ensure that health service personnel understand the risk to these women if their needs are not met.

BACKGROUND: The admission process to high secure care ought to ensure that those admitted (a) receive mental health care that meets their needs and (b) that this is provided at an appropriate level of security. AIMS: A study was undertaken to test the effectiveness of the gate keeping process according to these two criteria. METHOD All referrals for admission to Rampton high security hospital over one year were examined and, in addition, all women, all Anglo-Caribbeans and a random 50% sample of the Caucasian male majority were selected for interview. Each case was followed up for 12 months following the panel decision to determine his/her placement at that time. RESULTS: Of 138 referred, 56 (41%) were initially offered a bed although nearly half (66) had been subsequently admitted by the end of the study period. Seriousness of mental disorder and offence were independently associated with admission. After one year, one third of those admitted were no longer in high secure care. CONCLUSIONS: The variables predictive of admission (i.e. seriousness of both mental disorder and offence) suggest that the decision-making process was valid. Placement at 12 months tended to endorse the decision not to offer a bed, but it is more difficult to interpret the reverse as short admissions to high security for those who left within 12 months may have been appropriate. There was no apparent advantage in having a panel reviewing the decision of the assessing clinician.

Approximately 40% of people who sustain whiplash injuries, complain of chronic physical and psychiatric symptoms. Associations have been found between pre-accident physical symptoms and physical outcome and between pre-accident psychiatric variables and both physical and psychiatric outcome. There are no reported investigations of the association between pre-accident physical symptoms and psychiatric outcome. In this study, 33 consecutive cases of whiplash injury met inclusion criteria from a series of psychiatric reports used in civil litigation. Outcome was measured for each patient and correlated with a range of pre-accident physical and psychiatric variables using multivariate regression. There was no association between pre-accident psychiatric factors and overall outcome. Older age and a pre-accident history of musculoskeletal complaints correlated with the physical and psychiatric outcome. In whiplash injury, pre-accident psychiatric factors may have little bearing on long-term prognosis. Physical and psychiatric outcome of late whiplash syndrome is probably worse in older individuals and in patients with a pre-accident history of musculoskeletal complaints.

BACKGROUND: It is now generally acknowledged that alcohol abuse increases the risk of violence among people with major mental disorder. Studies in the 1980s and earlier, however, tended to report an inverse relationship between their alcohol use and violence. AIMS: A study was undertaken to test a hypothesis that among people with major mental disorder considered to pose a serious risk to others the likelihood of excessive alcohol consumption in a period leading up to a violent or dangerous act has increased over time. METHODS: Analysis was made of annual high security hospital admission cohort case register data of 1 January 1975 to 31 December 1999; alcohol use data were taken from interview and records, and problem drinking defined as consumption of alcohol in excess of 21 units per week during the 12 months prior to the index offence or act. RESULTS: There was a linear increase in the proportion of patients in five-year admission cohorts who had engaged in excessive alcohol consumption during the year prior to their index offence or act. The increase was steeper among women than men, but cut across all diagnosis and offending groups. It was strongly associated with increasing tendency to abuse illicit drugs. CONCLUSIONS: The greater proportion of patients affected by excessive alcohol consumption occurred in spite of a reduction over the same period in admission of people in the diagnostic groups most likely to be implicated in substance misuse (personality disorder). This increased trend may simply reflect similar trends in the general population, but may also be associated with a lack of services or current consensus on appropriate treatment for patients whose mental illness is complicated by excessive alcohol use. Regardless, the trend suggests a growing need for 'dual diagnosis' services within and outside high security hospital.

BACKGROUND: Illicit drug misuse by people with mental disorder in the community has been associated with increased risk of violence but not tested among inpatients. AIMS: To evaluate screening for illicit drugs and determine the period prevalence of use in one high security hospital. METHOD: A records study six and 18 months after introduction of random ward urine testing was followed by a true random prospective study. A random sub-sample of these tests was checked in the laboratory. RESULTS: In the first period there were few tests and patchy recording; during the second, both improved, but testing was not random. In the third period there were 217 tests (65% of those requested) in 33 days; 116 tests requested were not carried out, of which 42 were due to patient refusals. Correlations between dipstick and laboratory results, and research and central recording of tests were high. The rate of drug detection was no higher with true randomization. The hospital's central record was confirmed as a reliable and valid research tool with respect to illicit substances. In the year 2000 the central record showed 12 definite cases of illicit substance use in 153,887 patient days, but some for test refusals. CONCLUSIONS: Random, reliable urine drug testing can be implemented, with generally good cooperation between patients and staff. Contrary to popular belief, in this setting there was little misuse. Further research might test whether current extensive preventive measures are cost effective. The methodology might be applied in less controlled settings to test inpatient violence and substance misuse associations.

BackgroundSerious violence is an unusual but significant correlate of psychosis, and leads to the need for specialist secure psychiatric services. Most such service users have previously used general psychiatric services.AimsTo examine diagnostic and socio-demographic differences between high-security psychiatric service users from their peers in community services.MethodTwo groups of patients with psychosis were compared: a national sample of high-security hospital residents, and a sample of patients in contact with general psychiatric services.ResultsSchizophrenia was the almost invariable diagnosis for all special hospital patients. White patients in the community sample were significantly more likely to have affective components to their illness compared with African–Caribbean patients; unlike those in special hospitals. There was a small excess in the proportion of African–Caribbean patients in the special hospital group, controlling for diagnosis, gender and locality. Men were overrepresented in this group.ConclusionsAmong patients with psychosis, having a diagnosis of schizophrenia and being male increase the likelihood of special hospital admission. Suggestions that ethnic minority patients are much more likely to have engaged in serious violence and need high-security placement were not borne out.

INTRODUCTION: For England and Wales, Section 17 of the Mental Health Act 1983 allows for compulsorily detained patients to have trial leave (TL) between hospitals or from hospital to community to allow a period of testing readiness for a change in residency and/or legal status. The aim of this study was to document the use of TL for the largest sub-group of such patients within two discharge cohorts from one high security hospital and to test for correlates. METHOD: Data were collected from the special hospitals' case register for two Broadmoor Hospital discharge cohorts, 1984 and 1990-94, of offender patients with hospital orders under Home Office restrictions on discharge (Section 37/41). RESULTS: In 1984, only two of the 29 people leaving special hospital did so under trial leave arrangements, but by 1990 to 1994, 71% of restricted hospital order departures were under trial leave (92/130), a significant change in practice. Focusing on only the later cohort, women were disproportionately more likely to leave in this way. Trial leave was used more for patients with an index offence of homicide, similarly for violent offences but less so for sex offences. Nature of disorder did not have any bearing on the use of trial leave. Use of trial leave did not significantly shorten length of stay within the special hospital. CONCLUSION: Trial leave has become the most usual route out of special hospital, and is the departure route used almost exclusively for women patients, yet there appears to be no obvious advantage for the patient in shortening length of stay in high security. However, there is no way of knowing how long patients would have stayed had the option of trial leave not been available to them. Furthermore, no advantage for the public was found in the preferential use of TL for discharges to the community.

Background Few follow-up studies of mentally disordered offenders have taken into account time spent in the community at risk of reoffending when calculating reconviction rates. Method This small exploratory study examined the effect of discharge destination (community or hospital) on reconviction over a nine-year period in an annual discharge cohort (1984) of special hospital patients with personality disorder, controlling for time spent ‘at risk’ in the community. Results Those discharged directly to the community spent significantly more time at risk in the community during follow-up but they were no more likely to be reconvicted than those discharged via a less secure hospital. Discussion One possible explanation is that less secure hospital units are not specifically equipped to treat people with a personality disorder. Alternatively, clinicians may be correctly identifying patients who are at greater risk of reoffending and thus recommending a more staged rehabilitation back to the community. It was apparent that there are very few official data available about placements following absolute discharge. The implications for this and other studies of this type are discussed.

BackgroundSpecial hospitals in England provide psychiatric care and treatment in high security. Their future is often questioned.AimsTo test for variation in demand for high-security psychiatric services over one 10-year period.MethodThis study was from the special hospitals' case registers and hospital records. The main measures were numbers and annual rates for referrals and beds offered; the Mental Health Act 1983 (MHA) classification of mental disorder; adjusted population rates by health region; admission episodes; legal category of detention; admission source and type of offence.ResultsReferrals to special hospitals showed no decrease during the 10 years; an apparent increase may reflect under-recording before 1992. Admissions fell by about 16% over the 10 years, but with regional variation. Women, civil cases, admissions under the MHA classifications of psychopathic disorder or mental impairment and directly from a court on a hospital order were most affected. There was an increase in admissions of pre-trial and sentenced male prisoners, and of transferred hospital order patients from other hospitals.ConclusionsThere is continuing demand from all parts of the country for high-security hospital beds. The smaller numbers admitted appear to include more demanding cases.

BackgroundA considerable proportion of patients with personality disorder are discharged directly to the community from special (high-security) hospitals.AimsTo examine whether patients with personality disorder discharged directly to the community are more likely to be re-convicted than those transferred to psychiatric hospitals of lesser security.MethodRe-conviction data for a f ive-to nine-year follow-up were collected for a four-year (1988–1991) special hospital discharge cohort of patients with personality disorder.ResultsIndividuals discharged directly to the community were not significantly more likely to be re-convicted than those transferred to less secure psychiatric hospitals. However, patients discharged to the community without formal conditions of supervision were more likely to be re-convicted than those discharged to the community with conditions or those transferred to other psychiatric hospitals.ConclusionsFormal supervision after discharge may be more important than actual destination in influencing the likelihood of re-conviction.

All personnel within one UK emergency service who had been identified during a six-month period as having been on sick leave for eight consecutive weeks or more were identified. Those consenting were interviewed once using both a semi-structured questionnaire and standardised instruments. There were three main objectives: to discover the nature of the presenting problem in terms of illness or injury, the extent to which psychological problems presented and the relative importance of general and/or traumatic stressors. The resulting sample of 17 people accounted for 2–3% of the workforce. Fifteen agreed to take part and 13 to full interview. of the 14 who completed the Hilton Drinking Behaviour Questionnaire 10 exceeded the threshold consistent with problem drinking. The reason for sick leave in all these cases was recorded as physical injury only.

Background: Though slowly growing, knowledge about prisoners detained for having violated an Alien Act is still marginal and most studies involve detained asylum seekers in the USA and Australia. Little is known about prevalence rates of mental health disorders in such a population. The Brief Jail Mental Health Screening BJMHS has been demonstrated in other prison populations as a valid screening for serious mental illness. Aim: The aims of this study were to describe prevalence rates for mental disorders according to ICD-10 and to validate the BJMHS for this population. Methods: 80 inmates at a detention center for prisoners having violated the Swiss Aliens Act were surveyed using the BJMHS at their admission. The results were cross validated with the WHO Composite International Diagnostic Interview (CIDI). Results: When omitting disorders caused by smoking tobacco, 76% of the prisoners suffered from at least one mental disorder according to CIDI. Whereas the rates for disorders due to psychoactive substance use as well as schizophrenic and affective disorders were comparable with other prison populations, we found a specific increased reporting of phobic (14%) and post-traumatic stress disorders (23%).The BJMHS detected serious mental illness defined as schizophrenic or affective disorders with a sensitivity of 81.0% and a specificity of 74.6%. Discussion: As in other prison populations prevalence rates for mental disorders were markedly above the general population. The specific pattern with high rates of phobic as well as post-traumatic stress disorders may reflect the very often traumatic backgrounds of this population. Whereas the results for the validation of the BJMHS were even better than in other similar studies and the instrument proved to be practicable and helpful to detect serious mental illness, sensitivity for a screening tool of around 80% is still too low. Additionally the fact that other serious mental disorders are not covered emphasizes the importance of other elements in the screening process, including the need to have well-trained staff, and to have a low threshold for psychiatric examination

The majority of psychiatric patients, even those who also offend against the law, are likely to be served best by good community services but a few of them will need treatment in a secure hospital. Treatment in high security for patients from England and Wales is provided by three special hospitals. In the 1980s provision of medium-secure hospital units began, but there is still a considerable shortfall of such beds. Data from a variety of settings suggest that the continuing gap in medium-secure provision may be qualitative as well as quantitative. This paper considers the case for long-term medium security, and the likely size and nature of demand. It would be misleading to assume that those with long-term medium-security needs constitute a homogeneous group. Some new facilities, probably built on to existing medium secure hospital units, are likely to be needed; if estimates of real need for high-security places are correct, then some places already exist and are being used by default in the special hospitals. For some patients, notwithstanding the old image of special hospitals, these may be ideal placements if redesignated, even redesigned. A variety of provision and effective cooperation between purchasers and providers will be essential to satisfy real need and ensure that the number of patients needing secure accommodation remains more or less within present estimates. Copyright © 1996 Whurr Publishers Ltd.

Recent government U turn leaves police healthcare adrift from the NHS In December 2015, the UK government announced that planned changes to the commissioning of healthcare for people held in police custody in England and Wales would not proceed. These changes had been well considered (having been in planning since a key report by Lord Bradley in 20091), set out formally, and described as one route to securing excellence.2 The government announcement, however, means that the commissioning of these specialist health services will remain with police and crime commissioners instead of being transferred to the National Health Service. This sets police healthcare apart from all other healthcare services, including those that are provided in other parts of the criminal justice pathway. The decision represents a missed opportunity. It will prevent much needed service development and could set back current healthcare delivery. It represents a policy reversal that …

People with mental disorder and people who are violent are separately recognised as being at high risk of suicide. People detained in high security hospitals are recognised for their violence to others, but perhaps less so for their suicide potential. We aimed to investigate suicide rates among such patients during and after their high security hospital residency, and to establish risk factors for suicide.We extracted data from the Special Hospitals' Case Register on each person resident at any time between 1 January 1972 and 31 December 2000. Suicide rates were calculated for the whole period. We compared rates to the general population using standardised mortality ratios (SMRs). We used poisson regression to estimate the effects of gender, legal category of detention, offending history and length of admission on the suicide rate.Of the 5,955 individuals, 218 completed suicide. The suicide rate was nearly 7 times higher among resident men (SMR 662, 95% CI 478-845) and over 40 times higher in resident women (SMR 4,012, 95% CI 2,526-5,498) than in the general population; it was 23 times higher (SMR 2,325, 95% CI 1,901-2,751) and 45 times higher (SMR 4,486, 95% CI 2,727-6,245) among post-discharge men and women, respectively. The suicide rate was significantly higher among women than men inside high security but not after discharge.The suicide rate among high security hospital patients was significantly higher than in the general population. Women were especially at risk while resident, whereas for men, the risk was higher after discharge.

Of 253 patients in their first schizophrenic episode, 52 behaved in a way threatening to the lives of others before their admission to hospital. These 52 patients were studied from data collected at the time of their initial presentation. Despite a history of illness in excess of 1 year in 24 cases, and evidence that violence was motivated by psychotic symptoms in 23 cases, fewer than half of the patients were admitted to hospital as a direct result of their dangerous behaviour. Life-threatening behaviour was more common where the patient had been ill for longer, and where there were delusions of being poisoned.

Within the setting of a regional secure unit, all doses of medication given p.r.n. over three months were ascertained and the details of each administration determined from prescription charts and a semistructured interview with the nursing staff involved. Thirty-two patients were resident for all or part of the study, all compulsorily detained. Only 15 were given medication p.r.n.) compared with the other patients they were significantly younger and more likely to be detained under civil orders than under the criminal provisions of the Mental Health Act 1983. Rarely was the medication the sole intervention in a crisis. In terms of effects on the overall treatment programme of the patient, medication given p.r.n. seemed to have an impact in only one small subgroup.

BACKGROUND: Detention in high security hospitals tends to last several years during patients' early adulthood, yet romantic partnerships and sexuality have been little studied. AIMS: To study such relationships among these inpatients. METHOD: Patients were engaged in a confidential, purpose-designed semi-structured interview concerning their relationships and their views on those of others. RESULTS: Seven (of 10) women and 18 (of 24) men gave interviews. All but one had previously been sexually active. No previous relationship lasted into high security but half (15) reported a new relationship. Most emphasized the importance of caring in respect of sexual activity but sexual intimacy short of intercourse was reported. Most (17) could describe 'safe sex' practices, but few (5) had ever followed them. At least half had experienced seriously abusive sexual relationships in childhood. CONCLUSIONS: Patients appeared able to talk reliably about their romantic and sexual relationships, their interest in which did not cease on incarceration. Findings suggest that it is important for staff to have accurate information on these to ensure safety and adequate support.

Given something of an international panic about people with a mental disorder, perhaps the most important contribution to rational practice is to emphasise that such disorders account for a minute proportion of society's violence. In countries with modest criminal homicide rates of, say, 2-6 per 100000 population, people with schizophrenia are overrepresented in criminal homicide statistics compared with their representation in the general population.1 In Denmark there is even some evidence of an increase, since 1959, in the number of men with schizophrenia who kill someone within their family.2 Criminal homicide, however, is a highly selected type of unnatural death even in peacetime. For non-fatal violence, in the only true community survey of violence and mental disorder,3 people with schizophrenia, major affective disorder, substance misuse, or a combination of disorders were overrepresented in the violence groups. Even so, less than 10% of the people with pure schizophrenia reported having been violent in the 12 months before the interview. Furthermore, they accounted for less than 3% of the total violence reported in the sample. There are no data to support the media caricature of people with a mental disorder, the shunning of former patients by employers or neighbours, or the laws increasing constraints proposed by politicians pandering to public fears. If most of society can remain untroubled by schizophrenia, however, the 1% or so of the population that suffer from it, their families, and the victims of those few schizophrenic people who become violent deserve more than reassurances about probabilities. An association between two conditions suggests but does not establish a causal link. Studies of comparative illness and violence careers are an important next step. Two Scandinavian birth cohort studies compared the criminal careers of people who had been admitted to hospital for major mental disorders with those …

BackgroundIn the UK, people with mental disorder thought to pose a high risk of harm to others are usually put in a high-security (special) hospital. Little is known about what happens after that.AimsTo test a hypothesis that, under current services and laws (from the mid-1980s), no one leaving high-security hospitals remains indefinitely institutionalised.MethodThe special hospitals' case register was used for case ascertainment and admission data; post-discharge data were collected from multiple sources on patients discharged in 1984 (census date 31.12.1995).ResultsIn this discharge cohort (n=223), 36 (17%) did not return to the community: 17 died in special hospital and 19 continuously lived in other institutions until death or the census date. Over two-thirds of these had mental illness, were older on admission and had lived longer in special hospital than their better-rehabilitated peers. Offending history was irrelevant to this. Most post-discharge institution time was in open psychiatric hospital, or back in special hospital, not in medium secure units or prison.ConclusionsThe hypothesis was not sustained, but fewer people never reached the community than before the mid-1980s. Atypical antipsychotics might reduce this number. We found no justification for a new tier of long-term medium secure units.

BackgroundTragic and high-profile killings by people with mental illness have been used to suggest that the community care model for mental health services has failed.AimsTo consider whether such homicides have become more frequent as psychiatric services have changed.MethodData were extracted from Home Office-generated criminal statistics for England and Wales between 1957 and 1995 and subjected to trends analysis.ResultsThere was little fluctuation in numbers of people with a mental illness committing criminal homicide over the 38 years studied, and a 3% annual decline in their contribution to the official statistics.ConclusionsThere are many reasons for improving the resources and quality of care for people with a mental disorder, but there is no evidence that it is anything but stigmatising to claim that their living in the community is a dangerous experiment that should be reversed. There appears to be some case for specially focused improvement of services for people with a personality disorder and/or substance misuse.

BackgroundReform of mental health legislation for England and Wales is due. MHRTs offer an important check in the balance between patient and public rights.AimsTo study the quantity and outcome of MHRTs in special (high-security) hospitals.MethodData were extracted from the records of 1670 patients detained under mental illness or psychopathic disorder classifications in special hospitals during 1992.ResultsThere were 661 MHRT hearings, mostly requested by patients. Forty-three (7%) discharges were ordered, often without key data about continuing care in the written evidence. There were 56 recommendations for transfer to lesser security. Correlates of MHRT discharge were: female gender, younger age (in women), a legal classification of psychopathic disorder and shorter length of stay. Conditional discharge did not necessarily mean departure from special hospital.ConclusionsSpecial hospital MHRTs result in few changes in patient status. A probable need for improvement in the evidence put before an MHRT was found. Legislation reformers should consider an extension of MHRT powers to order transfer between levels of security.

Editor—With the publication of the Cullen report into the shooting of several children at a school in Scotland1 and the cross party support in parliament to increase the controls on handguns, the moment is ripe for the medical profession …