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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.

SummaryThe new Sentencing Council Guideline on sentencing offenders with mental disorders, effective from 1 October 2020, is essential reading for all psychiatrists who give evidence in the criminal courts, revealing something of required judicial thinking, our common ground on public safety concerns but differences in focus on culpability and punishment.

Relationships have been well established between adverse childhood experiences (ACEs) and later psychosis (29 systematic reviews) or violence (4 systematic reviews). To date, just one review has explored childhood maltreatment, specifically, and violence risk with psychosis. We conducted a systematic review and meta-analyses of a wider range of ACEs and later psychosis with actual violence compared with psychosis alone, violence alone or neither, completing searches in January 2021. In all, 15 studies met inclusion criteria, but only six included all four groups of interest. Two substantial studies recorded ACEs from sources independent of those affected and probably before emergent psychosis or violence; others relied on retrospective recall. Meta-analyses were possible only for within-psychosis-group comparisons; histories of physical abuse, sexual abuse, and having a criminal/violent parent or living with family alcohol/drug use were each associated with around twice the odds of psychosis with violence as psychosis alone. Although ACE measures in the four-way comparisons were too divergent for firm conclusions, abuse histories, and parental criminality emerged as likely antecedents, one study evidencing psychosis as mediating between ACEs and violence. Without longitudinal prospective study, pathways between ACEs and later problems remain unclear. Our findings add weight to the case for exploring ACEs in addition to abuse as possible indicators of later violence among people with psychosis and for trauma-informed interventions, which is important because some people are reluctant to disclose abuse histories.

The new Sentencing Council Guideline on sentencing offenders with mental disorders, effective from 1 October 2020, is essential reading for all psychiatrists who give evidence in the criminal courts, revealing something of required judicial thinking, our common ground on public safety concerns but differences in focus on culpability and punishment.

Background\udImprisonment impacts on lives beyond the prisoner's. In particular, family and intimate relationships are affected. Only some countries permit private conjugal visits in prison between a prisoner and community living partner.\ud\udAims\udOur aim was to find evidence from published international literature on the safety, benefits or harms of such visits.\ud\udMethods\udA systematic literature review was conducted using broad search terms, including words like ‘private’ and ‘family’, to maximise search sensitivity but strict criteria for inclusion – of visits unobserved by prison staff and away from other prisoners. All included papers were quality assessed. Two of us independently extracted data from included papers, according to a prepared checklist. Meta-analysis was considered.\ud\udResults\udSeventeen papers were identified from 12 independent studies, all but three of them from North America. The only study of health benefits found a positive association with maintaining sexual relationships. The three before-and-after study of partnership qualities suggested benefit, but conjugal visiting was within a wider family-support programme. Studies with in-prison behaviour as a possible outcome suggest small, if any, association, although one US-wide study found significantly fewer in-prison sexual assaults in states allowing conjugal visiting than those not. Other studies were of prisoner, staff or partner attitudes. There is little evidence of adverse effects, although two qualitative studies raise concerns about the visiting partner's sense of institutionalisation or coercion.\ud\udConclusions\udThe balance of evidence about conjugal visiting is positive, but there is little of it. As stable family relationships have, elsewhere, been associated with desistance from crime, the contribution of conjugal visiting to these should be better researched.

AimsAlcohol consumption is known to have a disinhibiting effect, and is associated with a higher likelihood of aggressive behaviour, especially among men. People with certain personality traits maybe more likely to behave aggressively when intoxicated, and there may also be variation by gender. We aimed to investigate whether the reason why men and women with certain personality traits are more likely to engage in violence may be because of their alcohol use.MethodThe Big Five personality traits and Anger-Hostility, alcohol consumption andviolence were measured by questionnaire in 15,701 nationally representativeparticipants in the USA. We tested the extent to which alcohol mediates therelationship between personality factors and violence in men and women.ResultsAgreeableness was inversely associated with violence in both genders. Alcoholmediated approximately 11% of the effect in males, but there was no evidence of an effect in females. Anger-hostility was associated with violence in both sexes, but alcohol mediated the effect only in males. We also found that Extraversion wasassociated with violence and alcohol use in males and females. Alcohol accountedfor 15% of the effect of extraversion on violence in males and 29% in females.ConclusionThe mechanism by which personality traits relate to violence may be different in men and women. Agreeableness and anger-hostility underpin the relationship between alcohol and violence in men, but not in women. Reducing alcohol consumption in men with disagreeable and angry/hostile traits would have a small but significant effect in reducing violence, whereas in women, reducing alcohol consumption among the extraverted, would have a greater effect.

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.

We sought evidence on quantifiable offspring outcomes, including problems, needs and strengths, associated with their experience of major parental psychiatric disorder(s), focusing on schizophrenia, affective illnesses and personality disorder(s). We were motivated by the absence of any systematic exploration of the needs of offspring of parents in secure hospitals. Seven electronic databases were searched to identify systematic reviews of studies quantifying offspring outcomes when a parent, or parent surrogate, has major psychiatric disorder(s). Our search (updated in February 2018) identified seven high-quality reviews, which incorporated 291 unique papers, published in 1974–2017. The weight of evidence is of increased risk of poor offspring outcomes, including psychiatric disorder and/or behavioural, emotional, cognitive or social difficulties. No review explored child strengths. Potential moderators and mediators examined included aspects of parental disorder (eg, severity), parent and child gender and age, parenting behaviours, and family functioning. This clinical review is the first review of systematic reviews to focus on quantifiable offspring problems, needs or strengths when a parent has major psychiatric disorder(s). It narratively synthesises findings, emphasising the increased risk of offspring problems, while highlighting limits to what is known, especially the extent to which any increased risk of childhood problems endures and the extent to which aspects of parental disorder moderate offspring outcomes. The absence of the reviews’ consideration of child strengths and protective factors limits opportunity to enhance offspring resilience.

Aims and methodTo understand experience of early imprisonment in one prison under low staffing levels. A researcher, independent of the prison, interviewed each prisoner soon after reception and 3–4 weeks later. The first question of the second interview was: ‘I’d like to start by asking you about your experience of the last 3–4 weeks in prison'. Data are verbatim answers to this. Narratives were brief, so responses from all 130 participants were analysed, using grounded theory methods.ResultsThe core experience was of ‘routine’ – characterised by repetitive acts of daily living and basic work, and little reference to life outside prison – generally resolved passively, towards boredom and ‘entrapment’.Clinical implicationsThis ‘routine’ seems akin to the ‘institutionalism’ described in the end days of the 1960s’ mental hospitals. In an earlier study of similar men at a similar stage of imprisonment, under higher staff:prisoner ratios, experience was initially more distressing, but resolved actively and positively, suggesting that staff loss may have affected rehabilitative climate.

AimsTo conduct a systematic review of reviews to investigate how military deployment of a parent affects his/her child, and the extent to which the child's own perspectives have been documented.BackgroundLengthy but finite disruptions to parenting in any form may affect child development and mental and physical health.Military deployment means weeks or months of separation from one parent.2016 figures for the U.S. military showed that 40.5% of military personnel have children, and of these 1.7 million children the largest percentage are aged between 0–5 years (37.8%).MethodSeven databases were searched: AMED, Web of Science, Scopus, EMBASE 1947, Joanna Briggs Institute EMP database, Ovid MEDLINE 1946 and PsycINFO 1806 from the inception of each electronic database until 31st March 2018.Inclusion criteria:Child and young adults aged 0–24 yearsEnglish language papers onlyAll papers being systematic reviews or meta-analysesA focus on documenting the effects on child outcomesData extracted included the review methods and child outcomes reported, including educational attainment; physical symptoms; mental illnesses or disorders; changes to behaviours, and effects on peer and parental relationships.ResultThe eight reviews identified included 32 common and relevant studies.Across the various studies, only about 20% of data came directly from children.Five papers extracted from the reviews identified parental deployment as having a negative effect on school attainment.Nine studies extracted from the review papers found a positive correlation between having a deployed parent and a greater chance of experiencing depressive symptoms and feelings of anxiety.Strong correlations of increased prevalence of both externalising & internalising behaviours were conclusively found in 7 of the reviews.Increased resilience was detailed in only one study featured in multiple reviews.Just one study featured across the reviews reported on physiological measures - adolescents with deployed parents had higher blood pressures and significantly higher heart rates and stress scores than civilian children.ConclusionMore research obtaining the viewpoint of the child directly and observation of such children is required to properly understand the effects on children with a deployed parent, without the interference of parent or teacher reporting bias. Additionally, with only one study reporting on increased offspring resilience there has been limited exploration of potential positive correlates, so further research regarding these is important.

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.

Expressing remorse - or not - appears to influence criminal justice outcomes, but preliminary exploration of both judicial and psychological concepts suggests they lack clarity. We asked the following questions: does psychosis impair capacity for, or expression of, remorse for a homicide or other serious harm to others? Is failure to express remorse for an offence associated with recidivism? We conducted systematic reviews of empirical literature on remorse for serious violence while psychotic, and on relationships between remorse and reoffending regardless of mental state. No articles on remorse for homicide or other serious violence while psychotic were identified. There is weak evidence that lack of remorse is associated with reoffending generally, but nothing specific to psychosis. The literature is strong enough to support a case for research into valid measurement of remorse for offending, associations of such measures with recidivism, and whether a change in remorse can be effected - or matters. It is not strong enough to support reliance on perceptions of the presence or absence of remorse as a basis for judicial decisions.

Background\ud Safe alternatives to custody for offenders with mental disorder are vital, not least as self‐harm, and violence rates are rising among them in prisons. In England and Wales, the Criminal Justice Act 2003 allows a mental health treatment requirement (MHTR) to supplement a community or suspended prison sentence, but this combination is poorly understood and rarely sought.\ud \ud Aim\ud To explore offenders' perspectives on the MHTR.\ud \ud Methods\ud We interviewed all 25 consenting offenders under an MHTR in two probation areas. Verbatim transcripts of their audio‐taped narratives were analysed using grounded theory methods.\ud \ud Results\ud Their core concern was “instability,” characterised by many health and social difficulties and resolved by achieving stability, which included not reoffending as well as becoming healthy, substance free, and “having a life.” Most considered that the MHTR helped their motivation and service provision, but some cited poor supervisor accessibility, supervisor role confusion, and sense of stigma under the order as stressful and threatening good outcomes.\ud \ud Conclusions\ud This first account of offenders' perspectives on the MHTR suggests a model in which, under it, offenders see themselves making progress as courts require. They understand the risk of return to court and imprisonment if in breach. This model of understanding how MHTRs work could provide for professional guidance and evaluation of their effectiveness.

Purpose of review\ud \ud The contribution of people with psychosis to homicide statistics is small, but there is a statistically significantly higher rate of homicide among them than in the general population. Legal authorities and the wider public call for more information. Our aim was a narrative synthesis of empirical literature generated by systematic searches for the five complete years 2013–2017.\ud Recent findings\ud One article showed that people with psychosis are five times more likely to be homicide victims than those without, but focus remains on perpetrators. Consensus is that although psychotic symptoms contribute to homicidal acts, so do many of the variables that increase homicide risk more generally – including substance use, trauma histories and access to weapons; thus, both the epidemiology of homicide and some details, like method, may be country specific. In 2013–2017, variation in service provision as a risk factor for homicide has emerged more clearly but, overall, research made few homicide-specific advances.\ud \ud Summary\ud Criminal homicide is, fortunately, uncommon in most countries. Homicides by people with psychosis are so rare that they do not rate mention in the 2013 United Nations Global Survey of Homicide. This may account for the limitations to much research for this group. Despite some homicide-specific evidence of advantage for early intervention for psychosis, impact of improving treatment – the most promising way forward – will generally have to be inferred from the not entirely satisfactory surrogate of effects of treatment on violent offending more generally

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.

When a mental health service user kills, concerns arise about that service. Our aim was to examine consequent reviews of services across the European Union (EU), Norway, and Switzerland. A systematic review of published literature and a questionnaire survey with a psychiatrist with forensic expertise from each EU country, Switzerland, and Norway were completed. Collated findings were circulated to respondents for correction and/or further observations. There were no relevant journal publications from the EU outside the UK. Survey responses came from 28 of 30 countries surveyed. An inquiry almost always occurred in four countries and at least sometimes in all but five others. Where an inquiry occurred, it was generally internal rather than by an independent body. The UK has a national inquiry database; Norway, the Netherlands, and Finland collect similar data nationally, but most EU countries do not. Legal (civil or criminal) or disciplinary proceedings were uncommon anywhere, but in France and in Italy a treating psychiatrist has been convicted of manslaughter; service authorities appear more-or-less immune everywhere. Except where inquiry is invariable, victims' relatives generally drive actions. The concept of individual inquiry after homicide is widely recognised and often occurs, but practice varies. The impact of such process still requires evaluation.

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.

Background. Repeated, self-damaging behaviour occurring in the context of borderline personality disorder (BPD) may reflect impairments in decision-making and planning cognition. However, there has been no systematic neuropsychological examination of these particular cognitive functions in patients diagnosed with BPD. Such investigations may improve our understanding of the possible role of brain dysfunction in BPD and improve the characterization of the psychological difficulties associated with this disorder.Method. Forty-two psychiatric patients with a diagnosis of DSM-III-R BPD (41 of whom gave a history of self-harm), without a history of specified ‘psychoses’ or current major affective disorder, were clinically assessed before completing computerized tasks of decision-making and planning previously shown to be sensitive to frontal lobe dysfunction, and tests of spatial and pattern visual recognition memory previously shown to be sensitive to frontal lobe damage and temporal lobe damage respectively. The performance of the BPD patient group was compared with that of a non-clinical control group consisting of 42 subjects.Results. The performance of the BPD patients on the decision-making task was characterized by a pattern of delayed and maladaptive choices when choosing between competing actions, and by impulsive, disinhibited responding when gambling on the outcome of their decisions. BPD patients also showed impairments on the planning task. There was no evidence of impaired visual recognition memory. Additional analyses suggested only limited effects of current medication and history of previous substance use disorder.Conclusions. These findings suggest that BPD is associated with complex impairments in dissociable cognitive processes mediated by circuitry encompassing the frontal lobes. These impairments may mediate some of the behavioural changes evident in BPD. Further work is needed to examine the specificity of these findings.

Convictions for taking, possessing and distributing pornographic photographs of children have increased with the growing use of the Internet. Previous studies of any progression to contact offences have been small scale and only a few of these have included an investigation of subsequent reconvictions for use of illegal and especially of child pornography. The aims of the present study are to compare reconviction rates among illegal pornography offenders with and without previous child contact offences. The former are referred to as “dual offenders”. This study is a national cohort study of all individuals in Switzerland convicted of an illegal pornography offence since 1973 and was followed-up until 1st November 2008. Reconvictions were ascertained using criminal records from the Federal Office of Justice of Switzerland, leading to a total of 4612 offenders, consisting of 4249 illegal pornography offenders and 363 dual offenders. Comparison of 3-year reconviction rates showed that only 0.2% of the illegal pornography offenders were convicted of contact child sex offences, whereas 2.6% of the dual offenders were reconvicted. The illegal pornography offenders were also significantly less likely to be convicted of further pornography offences, or indeed other sexual offences. The very low “progression rate” among illegal pornography offenders to contact child sexual offences, and their low rate of even repeat pornography offences suggests that community sentences remain appropriate. It is important, however, to bear in mind that conviction rates tend to underestimate the true offending rates, and that with greater access to the Internet, characteristics of pornography users may change over time.

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 Certified medical specialists, including forensic psychiatrists, from the 27 member states of the European Union (EU) may practise in each other's countries, but there are professional and legal differences between them. One may lie in whether a patient's treating doctor/clinician may give expert evidence about that person in court. Aims To examine similarities and differences between EU jurisdictions in law and practice in combining or separating such roles and to review the evidence in support of either position. Methods A psychiatrist with court experience was contacted in each EU country about law, practice and guidance on division of clinician–expert roles. Published literature was searched for an evidence base for practice in the field. Additional material is from discussion at a residential meeting of practising forensic psychiatrists from Austria, Belgium, Denmark, Germany, Hungary, the Netherlands, Switzerland and the UK. Results All acknowledge that a treating clinician can never be an independent expert in that case, but the 22 (of 27) EU countries responding vary in law and practice on whether the dual role may be assumed. There has been almost no research interest in factors relevant to separation of roles. International discussion revealed that ethical and practice issues are not straightforward. Conclusions On current evidence, either separation or combination of clinical and expert roles in a particular case may be acceptable. Insofar as there are national legal or professional guidelines on this issue, anyone practising in that country must follow them and may safely do so, regardless of practice in their native country. The most important ethical issue lies in clarity for all parties on the nature and extent of roles in the case. This paper has additional material online. Copyright © 2012 John Wiley & Sons, Ltd.

Alcohol is a preventable cause of illness, offending and other adversities worldwide. Prisoners are especially vulnerable. The aim of this study was to test the hypotheses that younger adult male prisoners are more likely to be hazardous drinkers than their older peers, but less likely to recognize this. The study cohort comprised 100 male prisoners aged 18-20 years and 157 aged 21 and over, who were interviewed and completed standard alcohol and drug questionnaires just after reception into prison. It was found that younger men were significantly more likely to be hazardous drinkers than their older peers but less likely to recognise this, even at scores on the Alcohol Use Disorders Identification Test (AUDIT) indicating dependency. They were also less likely to experience withdrawal symptoms, the main factor associated with problem drinking recognition at any age. Younger prisoners were less likely to be depressed, more likely to rate their social support as good and less likely to be dependent drug users. We conclude that reliance on younger prisoners to recognise their hazardous drinking would identify about one-fifth of them. With a lower likelihood of withdrawal symptoms than older men, they are probably still metabolizing alcohol more effectively. Given their similarities to older prisoners in terms of any previous imprisonment and likely personality disorder, formal screening for hazardous drinking might prevent decline into problem drug use, depression, reoffending, re-imprisonment, and social disconnection.

Objective. There is a suggestion in the literature that more variable affect increases suicidal ideation through the repeated re-activation of latent suicidal cognitions. The hypothesis that affective variability would be a better predictor of suicidal ideation and related behaviour than affect level was tested in individuals at ultra-high risk of developing psychosis. This study also examined the prediction that affective variability is a suicide-specific mechanism and would not predict levels of attenuated psychotic phenomena. Method. Twenty-seven ultra-high risk individuals were required to complete ambulant ratings of their affect when prompted by an electronic wristwatch for six days (the experience sampling method). In the debriefing session, participants were assessed with a semi-structured interview (the Comprehensive Assessment of At-Risk Mental State), which assessed the severity and frequency of suicidality and psychosis-related phenomena. Results. The variability of negative and positive affect was predictive of the frequency of suicidal thoughts and behaviour. More variable negative, but not positive affect, was also associated with more severe suicidal ideation and related behaviour. Affect variability was not significantly related to the severity of attenuated psychotic phenomena. Conclusion. Affective variability appears to be a specific risk factor for suicidal ideation in individuals at ultra-high risk of developing psychosis. Early intervention should focus on providing individuals with skills for regulating their own affect. Language: en

BackgroundIndividuals with repetitive or impulsive aggression in the absence of other disorders may be diagnosed with intermittent explosive disorder according to DSM–IV, but no such diagnostic category exists in ICD–10. Mood stabilisers are often used off-license for the treatment of aggression associated with a variety of psychiatric conditions, but their efficacy in these and in idiopathic aggression is not known.AimsTo summarise and evaluate the evidence for the efficacy of mood stabilisers (anticonvulsants/lithium) in the treatment of impulsive or repetitive aggression in adults.MethodA meta-analysis of randomised controlled trials that compared a mood stabiliser with placebo in adults without intellectual disability, organic brain disorder or psychotic illness, identified as exhibiting repetitive or impulsive aggression.ResultsTen eligible trials (489 participants) were identified A pooled analysis showed an overall significant reduction in the frequency/severity of aggressive behaviour (standardised mean difference (SMD) =–1.02, 95% CI −1.54 to −0.50), although heterogeneity was high (I2 = 84.7%). When analysed by drug type, significant effects were found in the pooled analysis of three phenytoin trials (SMD =–1.34, 95% CI −2.16 to −0.52), one lithium trial (SMD =–0.81, 95% CI −1.35 to −0.28), and two oxcarbazepine/carbamazepine trials (SMD =–1.20, 95% CI −1.83 to −0.56). However, when the results of only those studies that had a low risk of bias were pooled (347 participants), there was no significant reduction in aggression (SMD =–0.28, 95% CI −0.73 to 0.17, I2 = 71.4%).ConclusionsThere is evidence that mood stabilisers as a group are significantly better than placebo in reducing aggressive behaviour, but not all mood stabilisers appear to share this effect. There is evidence of efficacy for carbamazepine/oxcarbazepine, phenytoin and lithium. Many studies, however, were at risk of bias and so further randomised controlled trials are recommended.

Specialist forensic mental health service development continues worldwide. Given their generally small size and slow patient turnover, aggregating multi-site data could aid in the study of their effectiveness, safety, and value for money. The study compares such context of care and treatment philosophies in nine countries. National databases on demographics, mental disorders, and offending were identified. Participating forensic mental health practitioners independently rated likely outcomes for standard cases of serious offenders with psychosis or personality disorder. Gender distribution was similar between populations, but there were differences in age distribution and proportions of ethnic groups. Rates of psychosis were similar, but there were considerable population-based differences in substance misuse disorder rates, other substance misuse indicators and in criminal conviction statistics. Case analysis confirmed shared preferences for mental health disposals for people with psychosis, and penal di...

BACKGROUND: People with schizophrenia who offend do not constitute a homogenous population. Pre-illness characteristics may distinguish groups. AIMS: To test for differences in prevalence of childhood risk factors for offending between serious offenders with schizophrenia who had started offending before their first ever psychiatric admission (pre-admission offenders) and those who had started after it (post-admission offenders). Our hypothesis was that such adverse childhood factors would be more prevalent in the pre-admission offenders. METHOD: Retrospective interview and records case-control study of all first high security hospital admissions diagnosed with schizophrenia in England 1972-2000. Risk factors were identified by multivariate logistic regression. RESULTS: 853 patients were pre- and 741 post-admission offenders. Our hypothesis was confirmed in that factors associated with pre-admission offending were paternal criminal convictions, larger family size, and younger age at first use of illicit drugs, on first smoking cigarettes, and at maternal separation. There were differences too in pre-high security hospital treatment: pre-admission offenders had been younger at first court appearance and had more criminal justice system disposals, post-admission offenders were younger at first ever psychiatric hospital admission and more often hospitalized. CONCLUSIONS: While early offending among people with schizophrenia may delay treatment, making the distinction between pre-admission and post-admission offending may be useful in understanding the aetiology of the offending, and establishment of such a history may help in targeting interventions supplementary to treatment specific for the psychosis.

Forensic mental health services must be theoretically driven and subject to sound research evaluation if they are to be maximally effective. People who are trained in both clinical and research skills are ideally placed to ensure this, but now the clinician researcher is often under threat, regardless of clinical subject, professional discipline, or even country of residence. Although size is not the only factor, smaller fields, of which forensic mental health is one, tend to be particularly vulnerable. Funding appears to be disproportionately scarce for research into the difficulties and management of offenders who have a mental disorder, with some avenues, such as dedicated charitable funding, absent altogether. A range of the challenges and some possible solutions are considered with particular reference to Germany, Sweden, and the UK. It is as vital to good clinical practice as to the future of research to have the means to attract young scientists into the field.

Aim: To examine the experiences and attitudes of patients aged 60 and over who are resident in a high-security hospital, and their care staff, using qualitative research methodology, with a view to informing a service model for this group. Results: Of the 16 patients aged 60 and over resident in Broadmoor Hospital, 12 were interviewed, along with 21 members of staff. The patients were located on nine different wards, despite the existence of a specialist ward for older patients. The median duration of stay was 17 years. The large number of issues identified from the interviews fell into four broad clusters: quality of life, vulnerability, risk to others, and resources. An overarching theme emerged to do with the uniqueness of these older patients, in their difference both from younger high security peers and from people of similar age elsewhere. Conclusions: Care needs should not be assumed on the basis of age alone but must be individually assessed. Many older serious offenders with mental disorder have extensive experience of relevant services, are articulate, and, together with their care staff, could assist in shaping better services for a probably expanding population.

Among the many studies of the crime of homicide there is little evidence of interest in the practical management of those convicted. This study sought to compare two groups, identified within entirely different services, each with a different background of management. One was drawn from the probation service and the other from the health service. At the time of sentencing there were remarkably few group differences in demography, social or health status of the two groups of offenders, at least according to contemporaneous reports. The one significant difference was the higher rate of psychosis among those initially sent to hospital. Questions are raised about the diagnosis of personality disorder at the time of the trial and its effect on sentencing. Both hospital and probation staff seemed to be functioning on a dearth of important information. Closer liaison between probation and medical services, both within the prison and within the NHS, in assessing and planning the management of such people seems essential. Two case examples are included which illustrate the issues raised in the study. This study also provides further evidence of the need to review the mandatory life sentence for murder.

Psychosis confers a disproportionate risk of violence on women compared with men, but such women barely affect national crime statistics anywhere. Much research in the field does not include women at all. In our literature review, we found that information about women, psychosis and violence generally had to be extracted from studies including women but focussing on men; not uncommonly analyses 'controlled for gender' rather than treating it as interesting in itself. A tendency for women to be older than men at onset of psychosis may not apply to those who become violent, but women with psychosis do seem to start offending later and desist sooner. Rates of seriously adverse childhood experiences are similar between women and men with psychosis, except for sexual abuse-more frequently reported by the women. Some evidence of special patterns for women in the nature of psychosis and violence relationships requires more exploration, as do treatment questions. With so few women in any one service, multi-centre co-operation in research with them will be essential.

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.

In this study, response inhibition and associated neural activation during a motor inhibition paradigm were investigated in (i) men with antisocial personality disorder (APD) with a history of violence (n = 14), (ii) men with schizophrenia with a history of violence (n = 12), (iii) men with schizophrenia without a history of violence (n = 12), and (iv) healthy control subjects (n = 14) using functional magnetic resonance imaging (fMRI). At the behavioural level, individuals with schizophrenia showed impaired performance across all conditions, whereas an increased error rate was seen in the APD group only during the conditions requiring inhibition. At the neural level, both violent groups showed reduced thalamic activity, compared with controls, in association with modulation of inhibition by task demands. In addition, the violent schizophrenia group, compared with controls, showed reduced activity in the caudate nucleus during the condition requiring inhibition. It is concluded that violence may not be specifically associated with impaired voluntary inhibition in schizophrenia but this is likely in APD. Reduced thalamic function, perhaps due to its known association with sensorimotor disturbances, is implicated in violent behaviour across both disorders. In addition, caudate dysfunction may contribute, given its role in timing and temporal processing as well as suppression of motor actions, to deficient inhibition and violent behaviour in schizophrenia.

BACKGROUND: A new forensic mental health law was enacted in Japan in 2003, enabling development of specialist services. Before their establishment, it is important to determine the nature, frequency and correlates of the problems they are designed to ameliorate. AIMS: To establish rates of violent recidivism among mentally disordered offenders before the new legislation, and examine associated risk factors. METHOD: Data were extracted from one complete annual (1980) national cohort of people judged by the Court or prosecutor to be without responsibility for a criminal offence, or of sufficiently diminished responsibility for it to be diverted for psychiatric treatment. The outcome measure was violent recidivism after community discharge and before 1991. RESULTS: Fifty-two (10%) of 489 in the cohort were arrested or convicted of further violent offences. Violent recidivism was most strongly associated with a substance-related disorder, but histories of violence, homelessness and short index admissions were independently related. CONCLUSIONS: Violent recidivism was so unusual that, on this outcome, it could take many years to show any effect of the new service. Desistance from substance use, compliance with treatment and maintenance of stable housing may be better indicators of success, and their achievement a good preventive strategy.

Conducting a process evaluation of a complex intervention allows researchers to examine mechanisms of change not captured elsewhere. The MRC has published guidance[1] to support development of a streamlined approach and for reporting across public health interventions generally. Given the complex nature of the prison environment and in particular the many contextual factors that can impact on intervention delivery, a process evaluation is essential in a trial conducted in this setting. However, little guidance exists on the tailoring of process evaluations for complex environments where contextual factors may have a particularly significant impact. In this paper we present a process evaluation model for the Groups for Alcohol-misusing Short-term Prisoners (GASP) trial, following MRC guidance.