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Forensic mental health services in high income countries are typically high cost and low volume, providing care to people with mental illness, personality disorders, learning disability and autism deemed to pose a risk to others. Research into how forensic mental health services work as a whole system is limited. Such research is urgently needed to guide policy makers and ensure that services operate effectively.

It is not uncommon for people with mental illness to be convicted of a criminal offence. The relationship between the two is not necessarily simple. It may be diffuse and subtle, perhaps relating to the disinhibiting effect of severe mental illness or associated factors such as poor social integration, unemployment, lack of close and intimate relationships or substance misuse.

The psychiatric probation order has been a sentencing option for the courts for over fifty years. Many authors have lamented its underuse and described the inability of psychiatric and probation services to work together in a collaborative and effective way. The aim of this study was to describe probationers who had passed through Elliott House, a specialist bail and probation hostel for mentally disordered offenders. A retrospective case note review of all individuals who have been resident at Elliott House as a condition of a probation order was conducted. The individuals were mostly young, single men with a severe mental illness and comorbid substance misuse. As a group their previous contact with psychiatric services was irregular. A probation order at Elliott House appeared to provide social support and stability along with a period of regular psychiatric treatment and follow-up. The results suggest that psychiatric probation orders, if properly managed, can be a useful tool for both health and probation services in the short term.

This paper sets current proposals for reform of mental health legislation in the context of historical development of care for mentally disordered offenders and those who require similar services. The authors reflect on the fact that the National Service Framework and the various documents related to reform of the Mental Health Act 1983, seem to do little to address the area of the treatment of people suffering from psychiatric disorders who fall foul of the criminal justice system and bring little that is new to the field of forensic practice. They suggest that the ‘safety first’ approach seems still to be paramount.

In recent years there has been a marked increase in the proportion of individuals with mental disorders detained in hospital involuntarily, compared to those admitted on an informal basis (Wall et al, 1999). There is also growing concern about legally incompetent patients being treated under the doctrine of necessity (Eastman & Peay, 1998). The rise in the numbers of detained patients may have come about for a variety of reasons. Suggested possible contributory factors include a reduction in psychiatric hospital beds; the move towards community care and the consequent tendency to maintain patients at home for longer; increasing comorbidity and more severely disturbed behaviour on hospital wards; and a greater number of individuals transferred to hospital care from the criminal justice system (Mental Health Act Commission, 1999). Statutory mental health legislation in the UK has remained essentially unchanged, in some cases, for nearly 15 years. There have been additions and amendments during that period, as well as new law. For instance, the Mental Health (Patients in the Community) Act 1995, dealing with the care and treatment of people with mental disorders, and the Criminal Evidence (Amendment) Act 1994, covering specific issues to do with certain groups of those suffering from psychiatric disorders. Despite this there is clear evidence from recent research from various parts of the UK that medical practitioners, most particularly psychiatrists, and even those using the Mental Health Act on a day-to-day basis, do not necessarily possess a detailed knowledge of the law. Among a random sample of Section 12(2) approved medical practitioners in the West Midlands, none of those interviewed was able to define the term mental disorder as used in the Act, and only just over one-third correctly identified the four legal categories of mental illness, mental impairment, severe mental impairment and psychopathic disorder (Bhatti et al, 1999). In similar studies undertaken in Scotland, only one in 10 of a national sample of consultant psychiatrists was able to give the statutory definition of the term mental disorder (Humphreys, 1998) and among a similar non-consultant sample only 28% were able to give the correct title and year of the Mental Health (Scotland) Act 1984 (Humphreys, 1997). It would seem important, therefore, that psychiatrists do not become complacent about their knowledge and use of the Act, even though there has been considerable debate around the issue of how much expertise and precise factual knowledge of specific legislation is actually required.

A 'Diversion at the Point of Arrest' scheme was introduced in South Birmingham in 1992. An initial evaluation of the first 12 months demonstrated its apparent effectiveness. This paper provides a further description of all referrals to the substantive service for the 4-year period 1 November 1993 to 31 October 1997. There were 492 referrals of 420 individuals during the study period. The majority of those assessed were single, unemployed Caucasian males who were living alone. Of these, 95% were from Birmingham or the surrounding areas. The most frequent diagnosis made was schizophrenia, followed by drug or alcohol dependence and neuroses. Only 16 individuals disclosed a criminal history but 67% had had previous contact with psychiatric services. The majority of offences committed by those referred were public order or acquisitive, or involved destruction of property. This scheme has been successful in preventing some mentally disordered individuals being inappropriately taken into custody and has identifi...

The health needs of women imprisoned in England and Wales have not been systematically co-ordinated or evaluated. This review discusses the available literature on the health of women prisoners and highlights areas in need of improved service and research. The importance of taking the opportunity to improve the immediate and long-term health of incarcerated women is emphasised.

Forensic psychiatrists throughout mainland UK and Northern Ireland were sent a postal questionnaire to determine their practice in cases where a restriction order was deemed appropriate and also their attitudes to the use of restricted hospital orders. Data were obtained about the estimated number of reports completed by each respondent and recommendations for restriction orders. In particular, the reasons why a restricted hospital order might be recommended or considered appropriate were sought. Out of the original sample of 97 psychiatrists, 74 (76%) returned completed questionnaires. They had written in excess of 3,000 legal reports in the previous 12 months and 60 (81%) had been involved in cases where a restriction order was considered appropriate in the same period. Of the 74 who responded, 33 (45%) said that they would specify the need for a restriction order when necessary, 27 (36%) stated that they would make no mention of it, and the remainder said that their practice would vary. Time-l...

The aim of the study was to assess the effects of a number of physical factors on serial total creatine phosphokinase (CK) levels within the first few days of admission to an acute psychiatric ward. Patients (n=17) who received parenteral injections within 48 hours of admission were compared with those (n=30) who did not, looking at factors such as method of admission, alcohol use, presence of restraint and serial CK estimations. Those receiving injections had significantly raised CK levels over the first few days post-admission; these levels tended to normalise over 72 hours of admission. A small number of the patients who were given intramuscular injections demonstrated CK levels of over 1000 U/L. It is suggested that where CK levels are elevated, NMS should be excluded on clinical grounds. CK levels should return to normal over the next 72 hours (in the absence of NMS) if there are no further intramuscular injections.

Aims and methodA one-in-five random sample (n=104) of practitioners approved under Section 12(2) of the Mental Health Act 1983 in the West Midlands was selected. Opinions were sought on issues relating to current law and potential reform.ResultsEighty-three (80%) doctors were interviewed. Over half (52%) stated that the term ‘mental illness' in the Act was unsatisfactory. Two-thirds (68%) specified the need for a review of legislation relating to treatment in the community.Clinical implicationsThere was a diversity of views. This is likely to be reflected in the clinical practice of those interviewed. Many respondents believed that there was a need for reform in specific areas of the Act.

Sir: We read with interest the description by Nadkarni et al ([2000][1]) of their experience of running a psychiatric liaison service in a probation hostel. They note that “ there is only one bail hostel (in Birmingham) within the criminal justice system specifically for mentally disordered