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Foreign-born migrants are at elevated risk for developing serious forms of mental illness, and are over-represented in criminal justice and forensic mental health settings. This study compares the ...

In the fall 2021, immunity mandates/passports for COVID-19 started to be discussed and implemented globally. In addition to increasing vaccination levels, these interventions isolate non-immune individuals from various settings to reduce non-household transmission and severe/critical illness. This is based on the hypothesis that the non-immune are at high absolute risk of these outcomes. However, these absolute risks were not quantified in the literature such that the absolute risk reductions of isolation on these outcomes remain unknown. This study estimated these absolute risks from September to November 2021 prior to the emergence of Omicron (B.1.1.529) using known data on the risk of infection, transmission in non-household settings, and age-stratified severe/critical illness in non-immune individuals for the Delta (B.1.617.2) variant, focusing on the European Union, United Kingdom, United States, Canada, Australia, and Israel. This allowed us to quantify the absolute risk reductions of isolation on (1) non-household transmission from the non-immune and (2) severe/critical illness amongst the non-immune in these regions during this period. We observed that on any given day the absolute risk reductions of isolation were typically small for transmission in most types of non-household settings and severe/critical illness in most age-groups, especially those aged

BackgroundVaccine mandates and vaccine passports (VMVP) for SARS-CoV-2 are thought to be a path out of the pandemic by increasing vaccination through coercion and excluding unvaccinated people from different settings because they are viewed as being at significant risk of transmitting SARS-CoV-2. While variants and waning efficacy are relevant, SARS-CoV-2 vaccines reduce the risk of infection, transmission, and severe illness/hospitalization in adults. Thus, higher vaccination levels are beneficial by reducing healthcare system pressures and societal fear. However, the benefits of excluding unvaccinated people are unknown.MethodsA method to evaluate the benefits of excluding unvaccinated people to reduce transmissions is described, called the number needed to exclude (NNE). The NNE is analogous to the number needed to treat (NNT=1/ARR), except the absolute risk reduction (ARR) is the baseline transmission risk in the population for a setting (e.g., healthcare). The rationale for the NNE is that exclusion removes all unvaccinated people from a setting, such that the ARR is the baseline transmission risk for that type of setting, which depends on the secondary attack rate (SAR) typically observed in that type of setting and the baseline infection risk in the population. The NNE is the number of unvaccinated people who need to be excluded from a setting to prevent one transmission event from unvaccinated people in that type of setting. The NNE accounts for the transmissibility of the currently dominant Delta (B.1.617.2) variant to estimate the minimum NNE in six types of settings: households, social gatherings, casual close contacts, work/study places, healthcare, and travel/transportation. The NNE can account for future potentially dominant variants (e.g., Omicron, B.1.1.529). To assist societies and policymakers in their decision-making about VMVP, the NNEs were calculated using the current (mid-to-end November 2021) baseline infection risk in many countries.FindingsThe NNEs suggest that at least 1,000 unvaccinated people likely need to be excluded to prevent one SARS-CoV-2 transmission event in most types of settings for many jurisdictions, notably Australia, California, Canada, China, France, Israel, and others. The NNEs of almost every jurisdiction examined are well within the range of the NNTs of acetylsalicylic acid (ASA) in primary prevention of cardiovascular disease (CVD) (≥ 250 to 333). This is important since ASA is not recommended for primary prevention of CVD because the harms outweigh the benefits. Similarly, the harms of exclusion may outweigh the benefits. These findings depend on the accuracy of the model assumptions and the baseline infection risk estimates.ConclusionsVaccines are beneficial, but the high NNEs suggest that excluding unvaccinated people has negligible benefits for reducing transmissions in many jurisdictions across the globe. This is because unvaccinated people are likely not at significant risk – in absolute terms – of transmitting SARS-CoV-2 to others in most types of settings since current baseline transmission risks are negligible. Consideration of the harms of exclusion is urgently needed, including staffing shortages from losing unvaccinated healthcare workers, unemployment/unemployability, financial hardship for unvaccinated people, and the creation of a class of citizens who are not allowed to fully participate in many areas of society.RegistrationCRD42021292263FundingThis study received no grant from any funding agency, commercial, or not-for-profit sectors. It has also received no support of any kind from any individual or organization. BH is supported by a personal research grant from the University of Wroclaw within the “Excellence Initiative – Research University” framework and by a scholarship from the Polish Ministry of Education and Science. None of these institutions were involved in this research and did not fund it directly.Competing interestsThe authors have no competing interests to declare.Ethical approvalNot applicable. All the work herein was performed using publicly available data.Data reportingThe data used in this work are available at https://tinyurl.com/4m8mm4jh and https://decision-support-tools.com/.

ObjectiveTo evaluate the benefits of vaccine mandates and vaccine passports (VMVP) for SARS-CoV-2 by estimating the benefits of vaccination and exclusion of unvaccinated people from different settings.MethodsQuantified the benefits of vaccination using meta-analyses of randomized controlled trials (RCTs), cohort studies, and transmission studies to estimate the relative risk reduction (RRR), absolute risk reduction (ARR), and number needed to vaccinate (NNV) for transmission, infection, and severe illness/hospitalization. Estimated the baseline infection risk and the baseline transmission risks for different settings. Quantified the benefits of exclusion using these data to estimate the number of unvaccinated people needed to exclude (NNE) to prevent one transmission in different settings. Modelled how the benefits of vaccination and exclusion change as a function of baseline infection risk. Studies were identified from recent systematic reviews and a search of MEDLINE, MEDLINE In-Process, Embase, Global Health, and Google Scholar.ResultsData on infection and severe illness/hospitalization were obtained from 10 RCTs and 19 cohort studies of SARS-CoV-2 vaccines, totalling 5,575,049 vaccinated and 4,341,745 unvaccinated participants. Data from 7 transmission studies were obtained, totalling 557,020 index cases, 49,328 contacts of vaccinated index cases, and 1,294,372 contacts of unvaccinated index cases. The estimated baseline infection risk in the general population is 3.04%. The estimated breakthrough infection risk in the vaccinated population is 0.57%. Vaccines are very effective at reducing the risk of infection (RRR=88%, ARR=2.59%, NNV=39) and severe illness/hospitalization (RRR=89%, ARR=0.15%, NNV=676) in the general population. While the latter effect is small, vaccines nearly eliminate the baseline risk of severe illness/hospitalization (0.16%). Among an infected person’s closest contacts (primarily household members), vaccines reduce transmission risk (RRR=41%, ARR=11.04%, NNV=9). In the general population, the effect of vaccines on transmission risk is likely very small for most settings and baseline infection risks (NNVs ≥ 1,000). Infected vaccinated people have a nontrivial transmission risk for their closest contacts (14.35%), but it is less than unvaccinated people (23.91%). The transmission risk reduction gained by excluding unvaccinated people is very small for most settings: healthcare (NNE=4,699), work/study places (NNE=2,193), meals/gatherings (NNE=531), public places (NNE=1,731), daily conversation (NNE=587), and transportation (NNE=4,699). Exclusion starts showing benefits on transmission risk for some settings when the baseline infection risk is between 10% to 20%.ConclusionsThe benefits of VMVP are clear: the coercive element to these policies will likely lead to increased vaccination levels. Our study shows that higher vaccination levels will drive infections lower and almost eliminate severe illness/hospitalization from the general population. This will substantially lower the burden on healthcare systems. The benefits of exclusion are less clear. The NNEs suggest that hundreds, and even thousands, of unvaccinated people may need to be excluded from various settings to prevent one SARS-CoV-2 transmission from unvaccinated people. Therefore, consideration of the costs of exclusion is warranted, including staffing shortages from losing unvaccinated healthcare workers, unemployment/unemployability, financial hardship for unvaccinated people, and the creation of a class of citizens who are not allowed to fully participate in many areas of society.RegistrationThis study is not registered.FundingThis study received no grant from any funding agency, commercial, or not-for-profit sectors. It has also received no support of any kind from any individual or organization.

This chapter investigates the use of risk assessment instruments for sex offenders. Over the past 20 years, numerous risk assessment strategies and processes have been developed to assist clinicians in evaluating an individual’s risk to reoffend. Currently, actuarial and structured professional judgment are the competing and leading approaches in the risk assessment literature. Actuarial approaches are often described as mechanical, mathematically driven algorithms. Risk factors are explicit and fixed, and there is no professional or clinical input into what risk factors are selected or how they are weighed. Structured professional judgment (SPJ) approaches, however, are a guide rather than a formula. SPJ tools not only guide an assessor to consider empirically identified risk factors but also allow clinical flexibility with respect to how specific risk factors are weighed and how risk is ultimately determined. Despite the empirical strength of actuarial risk measures, SPJ tools have been broadly adopted, given their utility in risk management planning and clinical decision-making.

There is insufficient knowledge regarding outcomes among persons who are no longer supervised by the forensic mental health system, and consequently little data to inform public perception regardin...

BACKGROUND Developmental typologies regarding age of onset of violence and offending have not routinely taken account of the role of serious mental illness (SMI), and whether age of onset of offending in relation to onset of illness impacts on the manifestation of offending over the life course. AIMS To test whether forensic psychiatric patients can be classified according to age of onset of SMI and offending, and, if so, whether subtypes differ by sex. METHODS Details of all 511 patients enrolled into a large forensic mental health service in Ontario, Canada, in 2011 or 2012 were collected from records. RESULTS A latent profile analysis supported a 2-class solution in both men and women. External validation of the classes demonstrated that those with a younger age onset of serious mental illness and offending were characterised by higher levels of static risk factors and criminogenic need than those whose involvement in both mental health and criminal justice systems was delayed to later life. CONCLUSIONS Our findings present a new perspective on life course trajectories of offenders with SMI. While analyses identified just two distinct age-of-onset groups, in both the illness preceded the offending. The fact that our sample was entirely drawn from those hospitalised may have introduced a selection bias for those whose illness precedes offending, but findings underscore the complexity and level of need among those with a younger age of onset. Copyright © 2018 John Wiley & Sons, Ltd.

Given documented gender differences in risk factors and manifestations of violence, researchers have advocated for gender-sensitive approaches to violence risk assessment. This study compares male (n = 292) and female (n = 68) forensic psychiatric patients on an array of demographic, clinical, behavioral, and legal variables to gain a clearer understanding of the prevalence of different risk factors and types of violence in this population. We investigate the interrater reliability and item utility of the Historical, Clinical, Risk Management-20 (HCR-20:V2), and examine whether individual HCR-20 items exhibit differential relationships to the tool's summary risk rating across gender. More women carried a diagnosis of borderline personality disorder, whereas antisocial personality disorder, substance use problems and extensive criminal histories were more often noted in men. These clinical differences were reflected in the distribution of HCR-20 item and subscale scores across gender. Interrater re...

Objective: We examine the association between rates of homicide resulting in a mental health disposition (termed mentally abnormal homicide [MAH]) and homicides without such a disposition, as well as to province-wide psychiatric hospitalisation and incarceration rates. Method: In this population-based study, we investigate all adult homicide perpetrators ( n = 4402) and victims ( n = 3783) in Ontario from 1987 to 2012. We present annual rates of mentally abnormal and non–mentally abnormal homicide and position them against hospitalisation and incarceration rates. Results: Among the total sample of homicide accused, 3.7% were mentally abnormal. Most (82.5%) had a psychotic disorder at the time of the offense. Contrasted with declining hospitalisation, incarceration, and population homicide rates, the rate of MAH remained constant at an average of .07 perpetrators per 100,000 population. The rate of MAH was not associated with discharges from or average length of stay in psychiatric hospitals (ρ = 0.10; 0.34, P > 0.10), incarceration rates (ρ = 0.16, P = 0.42), or the total homicide rate (ρ = 0.25, P = 0.22). The proportion of MAH perpetrators with a substance use disorder increased modestly over time (β = 0.35, R2 = 0.12, P = 0.08). Conclusions: The rate of MAH has not changed appreciably over the past 25 years. Declining psychiatric service utilisation was not associated with the rate of homicide committed by people with mental illness and, secondarily, was not linked to increases in the population homicide or incarceration rates. Substance use has become a more prevalent problem for this population.

Developmental typologies regarding age of onset of violence and offending have not routinely taken account of the role of serious mental illness (SMI), and whether age of onset of offending in relation to onset of illness impacts on the manifestation of offending over the life course.To test whether forensic psychiatric patients can be classified according to age of onset of SMI and offending, and, if so, whether subtypes differ by sex.Details of all 511 patients enrolled into a large forensic mental health service in Ontario, Canada, in 2011 or 2012 were collected from records.A latent profile analysis supported a 2-class solution in both men and women. External validation of the classes demonstrated that those with a younger age onset of serious mental illness and offending were characterised by higher levels of static risk factors and criminogenic need than those whose involvement in both mental health and criminal justice systems was delayed to later life.Our findings present a new perspective on life course trajectories of offenders with SMI. While analyses identified just two distinct age-of-onset groups, in both the illness preceded the offending. The fact that our sample was entirely drawn from those hospitalised may have introduced a selection bias for those whose illness precedes offending, but findings underscore the complexity and level of need among those with a younger age of onset. Copyright © 2018 John WileySons, Ltd.

SummaryDespite evidence for their comparable efficacy, psychotherapy faces a dramatic decline relative to pharmacotherapy in psychiatry. A deep ideological reason for this decline centres on the belief that psychotherapy is a psychosocial treatment whereas pharmacotherapy is a biological treatment. Modern cognitive neuroscience demonstrates that this distinction is a myth.