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Objective: This study aimed to validate brief intake screens for serious mental illnesses among New Zealand male prisoners.Methods: A prospective survey of consecutively admitted male remanded and sentenced prisoners was conducted across two New Zealand sites. Participants completed the Brief Jail Mental Health Screen (BJMHS) and the English Mental Health Screen (EMHS) upon prison admission. The validation standard, the Mini International Neuropsychiatric Interview (MINI), was completed for all positive screens and a random selection of negative screens.Results: A total of 1,292 brief screens and 530 MINI screens were completed. Fifty-one percent of the participants met MINI criteria for one of five targeted major mental disorders. In this study, the BJMHS performed with lower sensitivity, higher specificity, a lower false-positive rate, a significantly higher false-negative rate, and a much higher referral rate than in the validating U.S. study. And in this study the EMHS performed with lower sensitivity, less specificity, higher false-positive and false-negative rates, and a moderately higher overall referral rate than in the validating U.K. study. For the BJMHS and EMHS, the majority of false-negative cases involved a mood disorder and few involved psychosis.Conclusions: Although the BJMHS and EMHS did not perform well in terms of screening for MINI diagnoses, they appeared to be good at identifying a core group of prisoners who are psychotic and most likely to require urgent or semi-urgent intervention by mental health services. The most favorable clinical outcomes were achieved by defining a positive screen as one in which either the EMHS or the BJMHS criteria were fulfilled. [ABSTRACT FROM AUTHOR]

Pediatric carpal fractures are rare and often difficult to detect. This paper reviews the current literature on pediatric non-scaphoid carpal fractures, with a case report of a lunate fracture associated with a distal radius and ulnar styloid fracture, managed nonoperatively in a 12-year-old boy. There is lack of consensus regarding the management of these fractures due to the low number of reported cases. A frequent lack of long-term follow-up limits our understanding of the outcomes, but good outcomes have been reported for both nonoperative and operative management. This case report brings attention to the current time period for the definition of delayed union in pediatric carpal fractures, and emphasizes the need for prolonged follow-up for the detection of delayed complications leading to functional impairment., Competing Interests: Conflicts of interest The authors have no conflicts of interest to declare., (© 2023 The Korean Society of Traumatology.)

Purpose: Chat Generative Pre-trained Transformer (ChatGPT) is a large language artificial intelligence (AI) model which generates contextually relevant text in response to questioning. After ChatGPT successfully passed the United States Medical Licensing Examinations, proponents have argued it should play an increasing role in medical service provision and education. AI in healthcare remains in its infancy, and the reliability of AI systems must be scrutinized. This study assessed whether ChatGPT could pass Section 1 of the Fellowship of the Royal College of Surgeons (FRCS) examination in Trauma and Orthopaedic Surgery., Methods: The UK and Ireland In-Training Examination (UKITE) was used as a surrogate for the FRCS. Papers 1 and 2 of UKITE 2022 were directly inputted into ChatGPT. All questions were in a single-best-answer format without wording alterations. Imaging was trialled to ensure ChatGPT utilized this information., Results: ChatGPT scored 35.8%: 30% lower than the FRCS pass rate and 8.2% lower than the mean score achieved by human candidates of all training levels. Subspecialty analysis demonstrated ChatGPT scored highest in basic science (53.3%) and lowest in trauma (0%). In 87 questions answered incorrectly, ChatGPT only stated it did not know the answer once and gave incorrect explanatory answers for the remaining questions., Conclusion: ChatGPT is currently unable to exert the higher-order judgement and multilogical thinking required to pass the FRCS examination. Further, the current model fails to recognize its own limitations. ChatGPT's deficiencies should be publicized equally as much as its successes to ensure clinicians remain aware of its fallibility., (© The Author(s) 2023. Published by Oxford University Press on behalf of Postgraduate Medical Journal. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: We present a novel approach for managing retinal detachment in a patient with aniridia related corneal scarring precluding fundal view via a deep anterior lamellar keratoplasty., Methods: A 30-year-old female patient who had bilaterally opaque cornea, due to advanced aniridia related keratopathy presented with, experiencing flashing of light in her right eye. Examination of the retinal fundus was not possible due to the dense corneal scarring and underlying cataract. A superior bullous macula off retinal detachment was diagnosed on ultrasonography. Visual acuity at presentation was hand motions. The corneal scarring extended to the mid to deep stroma. We performed a deep anterior lamellar dissection of the opacified corneal stroma, that allowed clear visualisation of a dense cataract. The cataract was removed by phacoemulsification and IOL inserted. This allowed to proceed with repair of retinal detachment, through pars plana approach. The surgery was completed by a donor deep lamellar keratoplasty., Results: This achieved a good fundal view to proceed with phacovitrectomy visualised through the residual corneal layers. Uneventful pars plana vitrectomy, cryotherapy and SF6 gas were performed to reattach the retina. Post-operatively the graft remains clear at 6 months with a visual acuity of 20/160 in the right eye, a level of vision the patient had not experienced for decades., Conclusion: Deep anterior lamellar keratoplasty offered an alternative to temporary keratoprosthesis to achieve a clear view of the retinal fundus and perform pars plana vitrectomy and repair of the retinal detachment., Competing Interests: The authors declare that they have no conflict of interest.

Available evidence suggests that persons with serious forms of mental illness are 4-10 times more likely to commit homicide as compared to non-affected members of the general population. The relationship between homicide and psychotic illness has now been subject to longitudinal investigation in six different populations across eight studies covering time periods over the last six decades. With the exception of one study, these investigations demonstrate that homicide associated with psychotic illness appears relatively stable through time and, in most populations, is not related to factors that contribute to the rise and fall of total population homicide (TPH) rates. This suggests that illness and treatment factors are of most importance if we are to reduce the prevalence of this tragic illness complication.

Background: Women comprise around 15% of admissions to provincial correctional institutions in Canada. Women in custody are known to have a high prevalence of mental health concerns, but little is known about how those referred to mental health services compare with referred men at a similar stage of imprisonment., Aims: Our aim was to describe and compare clinical, social and demographic characteristics of a complete cohort of custodially remanded men and women who were referred to mental health services while under custodial remand in two correctional institutions., Methods: We carried out retrospective analysis of data obtained from 4040 men and 1734 provincially detained women referred to mental health services in two correctional centres holding mainly pre-trial prisoners and serving a large mixed urban-rural catchment area in Toronto, Canada over a nearly five-year period. Men and women were first screened using the Brief Jail Mental Health Screen. Those who screened positive were assessed using the Jail Screening Assessment Tool the Brief Psychopathology Rating Scale-Expanded (BPRS-E) and the Clinical Global Impression-Corrections (CGI-C)., Results: There were many similarities between men and women, but also some important differences. Women were more socioeconomically disadvantaged than men. More women than men reported having children, yet fewer reported having any form of employment or social supports, although men were more likely to report unstable housing. In addition, women were significantly more likely to have mood and anxiety problems and to be self-harming, but did not differ from men in current psychotic symptoms. We also found differences in patterns of substance use, with a higher proportion of women using heroin and methamphetamines but fewer women having accessed addiction services., Conclusions: Our findings have implications for clinicians and service planners. They underscore the value of systematic screening for identifying need. More specifically, they suggest need for increased availability of addiction services for women as well as ensuring support for those women who have dependent-age children. Improvement in supports for entry into employment is particularly needed for women, while men are particularly likely to need access to stable housing., (© 2022 John Wiley & Sons Ltd.)

Chronic exposure to stressors and potentially psychologically traumatic events contributes to the high prevalence of mental health disorders in correctional workers (CWs) and other public safety personnel (PSP). Digital mental health interventions are an accessible and scalable method of improving and maintaining the mental health of this population. The current review explores the benefits of digital mental health interventions for PSP-with a focus on CWs-and how these innovations can address the limitations in in-person mental health care. A systematic literature search of five databases (Medline, PsycInfo, Embase, CINAHL, Google Scholar) was conducted until March 2022. The search yielded 16 publications that focused on digital mental health interventions or care available to CWs and other PSP. The benefits of digital innovations were summarized into five categories which discussed (1) their ability to enhance accessibility and reduce stigma; (2) the provision of evidence-based and structured psychotherapy programs; (3) variability in the degree of therapist engagement; (4) the integration of proactive interventions; and (5) enhancing engagement by acknowledging unique experiences and interpersonal relationships. Although digital mental health technologies for CWs are still in their infancy, there is strong evidence to support their effectiveness in ameliorating symptoms of mental distress. Future research should consider how ethnicity, gender, culture, sexual orientation, and socioeconomic status can be integrated into these therapies and how the interplay between different stakeholders and organizations can impact the effectiveness of online therapies and programs., Competing Interests: NA and MO cofounded an online care delivery platform (i.e., OPTT) and have ownership stakes in OPTT Inc. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Moghimi, Knyahnytska, Omrani, Nikjoo, Stephenson, Layzell, Frederic Simpson and Alavi.)

Introduction: Prone positioning is deployed as a critical treatment for improving oxygenation in patients with Acute Respiratory Distress Syndrome. This regimen is currently highly prevalent in the COVID-19 pandemic. The pandemic has brought about increased concern about how best to safely avoid brachial plexus injuries when caring for unconscious proned patients., Methods: A review of the published literature on brachial plexus injuries secondary to proning ventilated patients was performed. This was combined with a review of available international critical care guidelines in order to produce a succinct set of guidelines to aid critical care departments in reducing brachial plexus injuries during these challenging times., Discussion: There is no one manner in which prone positioning an unconscious patient can be made universally safe. This paper provides 6 key steps to reducing the incidence of brachial plexus injuries while proning and suggests a safe and sensible management and referral pathway for the conscious patient in which a brachial plexus injury is identified., Conclusion: There is in truth no completely safe position for every patient and certainly there will be anomalies in anatomy that will predispose certain individuals to nerve injury. Thus the injury rate cannot be reduced to zero but an understanding of the principles of protection will inform those undertaking positioning.

Amygdala-prefrontal cortex (PFC) functional impairments have been linked to emotion dysregulation and aggression in borderline personality disorder (BPD). Fatty acid amide hydrolase (FAAH), the major catabolic enzyme for the endocannabinoid anandamide, has been proposed as a key regulator of the amygdala-PFC circuit that subserves emotion regulation. We tested the hypothesis that FAAH levels measured with [ 11 C]CURB positron emission tomography in amygdala and PFC would be elevated in BPD and would relate to hostility and aggression. Twenty BPD patients and 20 healthy controls underwent FAAH genotyping (rs324420) and scanning with [ 11 C]CURB. BPD patients were medication-free and were not experiencing a current major depressive episode. Regional differences in [ 11 C]CURB binding were assessed using multivariate analysis of covariance with PFC and amygdala [ 11 C]CURB binding as dependent variables, diagnosis as a fixed factor, and sex and genotype as covariates. [ 11 C]CURB binding was marginally elevated across the PFC and amygdala in BPD (p = 0.08). In a priori selected PFC, but not amygdala, [ 11 C]CURB binding was significantly higher in BPD (11.0%, p = 0.035 versus 10.6%, p = 0.29). PFC and amygdala [ 11 C]CURB binding was positively correlated with measures of hostility in BPD (r > 0.4; p < 0.04). This study is the first to provide preliminary evidence of elevated PFC FAAH binding in any psychiatric condition. Findings are consistent with the model that lower endocannabinoid tone could perturb PFC circuitry that regulates emotion and aggression. Replication of these findings could encourage testing of FAAH inhibitors as innovative treatments for BPD.

We describe the application of a life-trajectory model of suicide to the prison setting and its implication for suicide risk detection. A model has been developed that describes two distinct trajectories culminating in suicide: one with large amounts of adversity early in life with a young age of suicide and another with chronic, gradually accumulating adversity with a later age of suicide. Support for applying the life-trajectory model to the prison population is found in prison-centric models of suicidal behavior and clinical profiles of individuals at high risk of suicide in prisons. We also describe how the life-trajectory model applies to two recent high-profile suicides within the Canadian prison system. Finally, we propose a screening tool based on the life-trajectory model to quantify an individual's adversity burden at intake and subsequently throughout incarceration. We describe how this proposed tool may improve detection of individuals with increased risk of suicide and describe the steps necessary for the development of this tool., (© 2017 American Academy of Psychiatry and the Law.)

E-mail communication is pervasive. Since many forensic psychiatrists have their e-mail addresses available online (either on personal websites, university websites, or articles they have authored), they are likely to receive unsolicited e-mails. Although there is an emerging body of literature about exchanging e-mail with patients, there is little guidance about how to respond to e-mails from nonpatients. Therefore, we used a Delphi technique to develop a consensus about salient points for the forensic psychiatrist to consider regarding responding to e-mails from nonpatients and the risks entailed. Four scenarios are described, including e-mails from nonpatients and unknown others requesting advice or help. The potential ethics-related, legal, moral, and practical concerns for forensic psychiatrists are discussed. Finally, potential pitfalls for forensic psychiatrists are described., (© 2016 American Academy of Psychiatry and the Law.)

Previous studies of decisions about forensic patients' placement in secure hospitals indicate some changes over time in the use of empirically supported risk factors. Our aim was to investigate whether, in more recent cases, risk assessment instruments were cited by a forensic patient review board or by the clinicians who made recommendations to the board and whether there was evidence of an association between risk assessment results and either dispositions or recommendations. Among review board hearings held in 2009-2012 pertaining to 63 different maximum security patients found not criminally responsible on account of mental disorder in Ontario, Canada, dispositions were most strongly associated with psychiatrists' testimony, consistent with previous studies. However, dispositions were associated with the scores on the Violence Risk Appraisal Guide (VRAG), such that transferred patients had a lower risk of violent recidivism than detained patients. An association between clinical opinions and risk assessment results was also evident and significantly larger than in previous research. There was no evidence that risk assessment was cited selectively in higher risk cases or when scores were concordant with the review board decision. This research may provide a baseline for studies of the effect of 2014 legislation introducing a high-risk designation for forensic patients in Canada. We recommend further efforts to measure the effect of nonpharmacological treatment participation and in-hospital security decisions on forensic decision-making. (PsycINFO Database Record, ((c) 2016 APA, all rights reserved).)

Individuals with serious mental illness (SMI; i.e., psychotic or major mood disorders) are vulnerable to experiencing multiple forms of adverse safety events in community settings, including violence perpetration and victimization. This study investigates the predictive validity and clinical utility of modifiable risk factors for violence in a sample of 87 forensic psychiatric patients found Not Criminally Responsible on Account of Mental Disorder (NCRMD) transitioning to the community. Using a repeated-measures prospective design, we assessed theoretically based dynamic risk factors (e.g., insight, psychiatric symptoms, negative affect, treatment compliance) before hospital discharge, and at 1 and 6 months postdischarge. Adverse outcomes relevant to this population (e.g., violence, victimization, hospital readmission) were measured at each community follow-up, and at 12 months postdischarge. The base rate of violence (23%) was similar to prior studies of discharged psychiatric patients, but results also highlighted elevated rates of victimization (29%) and hospital readmission (28%) characterizing this sample. Many of the dynamic risk indicators exhibited significant change across time and this change was related to clinically relevant outcomes. Specifically, while controlling for baseline level of risk, fluctuations in dynamic risk factors predicted the likelihood of violence and hospital readmission most consistently (hazard ratios [HR] = 1.35-1.84). Results provide direct support for the utility of dynamic factors in the assessment of violence risk and other adverse community outcomes, and emphasize the importance of incorporating time-sensitive methodologies into predictive models examining dynamic risk. (PsycINFO Database Record, ((c) 2016 APA, all rights reserved).)

Objective: The authors measured use of mental health services among young people before and during incarceration., Methods: Administrative data were used to describe mental health services received by 13,919 youths and young adults (ages 12-24) while incarcerated in Ontario, Canada, correctional centers (physician visits, April 1, 2010-March 31, 2012) and, for a subset of the population, during the five years prior to incarceration., Results: Forty-two percent had a mental health-related visit during incarceration. Thirty-five percent had no mental health contact for five years before the beginning of the correctional episode. Forty percent of individuals with schizophrenia had a psychiatric hospitalization in the year before entering custody., Conclusions: For one-third of young people with a mental health visit while incarcerated, the visit was the first mental health contact in at least five years. Yet high use of psychiatric services before entering custody among individuals with schizophrenia may indicate gaps in continuity of mental health care.

Impulsivity is a core feature of antisocial personality disorder (ASPD) associated with abnormal brain function and neurochemical alterations. The ventral striatum (VS) is a key region of the neural circuitry mediating impulsive behavior, and low monoamine oxidase-A (MAO-A) level in the VS has shown a specific relationship to the impulsivity of ASPD. Because it is currently unknown whether phenotypic MAO-A markers can influence brain function in ASPD, we investigated VS MAO-A level and the functional connectivity (FC) of two seed regions, superior and inferior VS (VSs, VSi). Nineteen impulsive ASPD males underwent [(11)C] harmine positron emission tomography scanning to measure VS MAO-A VT, an index of MAO-A density, and resting-state functional magnetic resonance imaging that assessed the FC of bilateral seed regions in the VSi and VSs. Subjects also completed self-report impulsivity measures. Results revealed functional coupling of the VSs with bilateral dorsomedial prefrontal cortex (DMPFC) that was correlated with VS MAO-A VT (r=0.47, p=0.04), and functional coupling of the VSi with right hippocampus that was anti-correlated with VS MAO-A VT (r=-0.55, p=0.01). Additionally, VSs-DMPFC FC was negatively correlated with NEO Personality Inventory-Revised impulsivity (r=-0.49, p=0.03), as was VSi-hippocampus FC with Barratt Impulsiveness Scale-11 motor impulsiveness (r=-0.50, p=0.03). These preliminary results highlight an association of VS MAO-A level with the FC of striatal regions linked to impulsive behavior in ASPD and suggest that phenotype-based brain markers of ASPD have relevance to understanding brain function., (Copyright © 2016 Elsevier B.V. and ECNP. All rights reserved.)

Research on violence perpetrated by individuals with major mental illness (MMI) typically focuses on the presence of specific psychotic symptoms near the time of the violent act. This approach does not distinguish whether symptoms actually motivate the violence or were merely present at the material time. It also does not consider the possibility that non-illness-related factors (e.g., anger, substance use), or multiple motivations, may have been operative in driving violence. The failure to make these distinctions clouds our ability to understand the origins of violence in people with MMI, to accurately assess risk and criminal responsibility, and to appropriately target interventions to reduce and manage risk. This study describes the development of a new coding instrument designed to assess motivations for violence and offending among individuals with MMI, and reports on the scheme's interrater reliability. Using 72 psychiatric reports which had been submitted to the court to assist in determining criminal responsibility, we found that independent raters were able to assess different motivational influences for violence with a satisfactory degree of consistency. More than three-quarters (79.2%) of the sample were judged to have committed an act of violence as a primary result of illness, whereas 20.8% were deemed to have offended as a result of illness in conjunction with other non-illness-based motivating influences. Current findings have relevance for clarifying the rate of illness-driven violence among psychiatric patients, as well as legal and clinical issues related to violence risk and criminal responsibility more broadly., (PsycINFO Database Record (c) 2016 APA, all rights reserved.)

Objective: Various forms of compulsory psychiatric community treatment orders (CTOs) are commonly utilized internationally. CTOs remain contentious because of the ethical implications of coercing patients to receive treatment. Understanding patients' experience of CTOs can assist in the development of more patient-centered and recovery-focused community care. This review examined the relationship between CTOs and patients' perceptions of coercion in the literature., Methods: A search of key terms relating to CTOs and patients' perceptions of coercion was conducted of relevant databases from their inception to March 31, 2014. Publications were included if they were peer reviewed, reported on original research, surveyed or interviewed patients who were or had been subject to a CTO, and were written in English. Factors influencing patients' perceptions of coercion, including the regional context of the studies, were identified., Results: Twenty-three primary research articles, reporting on 14 studies from seven countries, were included. Evidence indicated that CTOs may contribute to a patient's sense of coercion, with marked variations among studies in the levels of coercion. Contextual factors, including perceptions of alternatives to CTOs, the presence of additional forms of leverage in patients' lives, and the process of CTO initiation and enforcement, may mitigate or enhance perceptions of coercion., Conclusions: Coercive elements of CTOs may be reduced through increased patient access to information, better working relationships with service providers, and accessible, fair processes. The coercive aspects of CTOs should be seen as part of a broader understanding of the daily pressures and leverage applied in outpatient psychiatric treatment.

Objective: To identify subgroups of forensic psychiatric patients based on the age onset of serious mental illness and offending and assess the external validity of the subgroups with theoretically based sociodemographic, clinical, legal and risk-related variables., Method: The age onset of serious mental illness and criminal contact was ascertained for a sample of 232 patients. A range of sociodemographic, clinical, legal and risk-related variables were coded to assess whether age onset subgroups differed in a manner consistent with the literature on typologies of mentally ill offenders., Results: One-quarter of the sample was classified as early starters (patients whose first offense occurred before becoming mentally ill), while two-thirds were late starters (where first offense occurred following illness onset). A small percentage (8%) of patients were deemed late late starters, defined as late starters who had experienced 10+ years of illness and were >37 years upon first arrest. A larger proportion of early starters had a substance use disorder, antisocial personality disorder and a greater number of static/historical risk factors for violence. Early starters were younger upon first arrest and had more previous criminal contacts compared to late starters and late late starters. Mental illness was found to start later in life for late late starters; this group was also more likely to have been married and to have a spouse as victim in the index offense., Conclusion: We found support for distinct subgroups of mentally ill offenders based on the age onset of illness and criminal contact. Compared to late starters, offenses committed by early starters may be motivated more frequently by antisocial lifestyle and attitudes, as well as more instrumental behaviors related to substance abuse. In addition, late late starters may represent a distinct third subgroup within late starters, characterized by relatively higher levels of functioning and social stability; future work should replicate. Findings suggest different rehabilitation needs of the subgroups., (© The Royal Australian and New Zealand College of Psychiatrists 2015.)

Antisocial personality disorder (ASPD) often presents with highly impulsive, violent behavior, and pathological changes in the orbitofrontal cortex (OFC) and ventral striatum (VS) are implicated. Several compelling reasons support a relationship between low monoamine oxidase-A (MAO-A), an enzyme that regulates neurotransmitters, and ASPD. These include MAO-A knockout models in rodents evidencing impulsive aggression and positron emission tomography (PET) studies of healthy subjects reporting associations between low brain MAO-A levels and greater impulsivity or aggression. However, a fundamental gap in the literature is that it is unknown whether brain MAO-A levels are low in more severe, clinical disorders of impulsivity, such as ASPD. To address this issue, we applied [(11)C] harmine PET to measure MAO-A total distribution volume (MAO-A VT), an index of MAO-A density, in 18 male ASPD participants and 18 age- and sex-matched controls. OFC and VS MAO-A VT were lower in ASPD compared with controls (multivariate analysis of variance (MANOVA): F2,33=6.8, P=0.003; OFC and VS MAO-A VT each lower by 19%). Similar effects were observed in other brain regions: prefrontal cortex, anterior cingulate cortex, dorsal putamen, thalamus, hippocampus, and midbrain (MANOVA: F7,28=2.7, P=0.029). In ASPD, VS MAO-A VT was consistently negatively correlated with self-report and behavioral measures of impulsivity (r=-0.50 to -0.52, all P-values<0.05). This study is the first to demonstrate lower brain MAO-A levels in ASPD. Our results support an important extension of preclinical models of impulsive aggression into a human disorder marked by pathological aggression and impulsivity.

This paper is based on the report following the National Research Agenda Meeting on Mental Health, Justice, and Safety held in Montreal on November 19, 2014, which convened academics; health, social, and legal professionals; and people with lived experience of mental illness from across Canada. The goal was to identify research priorities addressing relevant knowledge gaps and research strategies that can translate into public policy action and improvements in evidence-based services. Participants identified key challenges: (1) inadequate identification and response to needs by civil mental health services and frontline law enforcement, (2) limited specialized resources in forensic and correctional settings, (3) fragmented care and gaps between systems, (4) limited resources for adequate community reintegration, and (5) poor knowledge transfer strategies as obstacles to evidence-based policies. Knowledge gaps were identified in epidemiology and risk reduction, frontline training and programs, forensic and correctional practices, organizations and institutions, knowledge transfer, and rehabilitation. Finally, participants identified potential sources of support to conduct real time research with regard to data collection and sharing. The findings represent a roadmap for how forensic mental health systems can best proceed to address current challenges through research and practice initiatives, drawing from lived, clinical and research experiences of a multidisciplinary group of experts.

Background: Few studies have investigated absconding from forensic hospitals and there are no published studies of interventions aimed at reducing these incidents in forensic settings. We present a study of the impact of a new policy using structured professional judgment and an interdisciplinary team-based approach to granting privileges to forensic patients. We assess the impact of this policy on the rate and type of absconding from a metropolitan forensic facility., Methods: Following concern about the rate of absconding at our hospital, a new policy was implemented to guide the process of granting hospital grounds and community access privileges. Employing an A-B design, we investigated the rate, characteristics, and motivations of absconding events in the 18 months prior to, and 18 months following, implementation of this policy to assess its effectiveness., Results: Eighty-six patients were responsible for 188 incidents of absconding during the 42-month study window. The rate of absconding decreased progressively from 17.8% of all patients at risk prior to implementation of the new policy, to 13.8% during implementation, and further to 12.0% following implementation. There was a differential impact of the policy on absconding events, in that the greatest reduction was witnessed in absconsions occurring from unaccompanied passes; this was offset, to some extent, by an increase in absconding occurring from within hospital units or from staff accompanied outings. Seven of the absconding events included incidents of minor violence, and two included the commission of other illegal behaviors. The most common reported motive for absconding across the time periods studied was a sense of boredom or frustration. Discharge rate from hospital was 22.9% prior to the implementation of the policy to 22.7% after its introduction, indicating no change in the rate of patients' eventual community reintegration., Conclusions: A structured and team-based approach to decision making regarding hospital grounds and community access privileges appeared to reduce the overall rate of absconding without slowing community reintegration of forensic patients.

Internationally, civil commitment laws have gone through substantial reforms in the past 50 years. Discernible shifts from the medically paternalistic to the excessively legalistic may be giving way to a blending of legislative intent under the rubric of therapeutic jurisprudence. In the light of those international movements, Shao and Xie describe how China's new mental health law shows the impact of these international and local influences on the development and practice of mental health law in China. The new Law was passed in 2012. It sets a broad vision for mental health services and mental health promotion in Chinese society as well as providing the legal framework for civil commitment. Practicalities of implementation may be highly significant in the success of the legislation., (© 2015 American Academy of Psychiatry and the Law.)

Introduction: The larynx is an intricate structure serving three important functions in humans: it protects the lower respiratory airway, facilitates respiration and helps produce sound through a key role in phonation., Objective: We report the first published finding of congenital duplication of the larynx in a patient with previously cleared squamous cell carcinoma of the neck and a new diagnosis of squamous cell carcinoma of the lung., Case Report: We describe the incidental finding of duplication of the larynx in a 62-year-old man with previously completely cleared squamous cell carcinoma of the neck, who presented with worsening dyspnoea. We also provide a brief overview of other published cases in which duplication of the vocal folds and epiglottis has been reported., Results: Our patient experienced no symptoms related to this incidental finding of congenital duplication of the larynx., Conclusion: The first case of congenital duplication of the larynx is currently of academic interest only; however, the possible association with squamous cell carcinoma is postulated to raise awareness in clinicians who may observe further cases in the future.

Objective: Prevention of self-injurious behaviour is an important priority in correctional settings given higher rates among inmates. Our study estimated the reported incidence of self-injury during the first 180 days in prison and tested potential risk and protective factors using official prison records., Methods: We conducted a retrospective cohort study using secondary data for 5154 admissions to the Correctional Service of Canada during 2011. Relative risks were estimated with Poisson regression. Recursive partitioning was used to create a parsimonious model of characteristics of offenders who engage in self-injury., Results: Thirty-six of 5154 (0.7%) offenders engaged in 1 or more incidents of self-injury during their first 180 days of incarceration. Educational and occupational achievement, family history, demographic factors, mental health service use, and results of mental health screening at intake were predictive of self-injury. Recursive partitioning models identified about 23% of inmates who presented with multiple risk factors, and had increased incidence of self-injury. A comparison of a model using information at intake to a model also incorporating events in prison suggested that events in prison added little to the detection of self-injury., Conclusions: Given high rates of most risk factors, screening for self-injury during early incarceration will be overinclusive. However, it may identify a group of inmates with complex needs for whom interdisciplinary responses are needed to address wide-ranging social, family, behavioural, and mental health deficits.

Background: Absconding from hospital is a significant health and security issue within psychiatric facilities that can have considerable adverse effects on patients, their family members and care providers, as well as the wider community. Several studies have documented correlates associated with absconding events among general psychiatric samples; however, few studies have examined this phenomenon within samples of forensic patients where the perception of threat to public safety in the event of an unauthorized absence from hospital is often higher., Methods: We investigate the frequency, timing, and determinants of absconding events among a sample of forensic psychiatric patients over a 24-month period, and compare patients who abscond to a control group matched along several sociodemographic and clinical dimensions. We explore, in a qualitative manner, patients' motives for absconding., Results: Fifty-seven patients were responsible for 102 incidents of absconding during the two year study window. Forensic patients who absconded from hospital were more likely to have a history of absconding attempts, a diagnosed substance use disorder, as well as score higher on a structured professional violence risk assessment measure. Only one of the absconding events identified included an incident of minor violence, and very few included the commission of other illegal behaviors (with the exception of substance use). The most common reported motive for absconding was a sense of boredom or frustration., Conclusions: Using an inclusive definition of absconding, we found that absconding events were generally of brief duration, and that no member of the public was harmed by patients who absconded. Findings surrounding the motivations of absconders suggest that improvements in therapeutic communication between patients and clinical teams could help to reduce the occurrence of absconding events.

Background: Past studies have identified poor rates of detection of mental illness among inmates. Consequently, mental health screening is a common feature to various correctional mental health strategies and best practice guidelines. However, there is little guidance to support the selection of an appropriate tool. This systematic review compared the sensitivity and specificity of mental health screening tools among adult jail or prison populations., Methods: A systematic review of MEDLINE and PsycINFO up to 2011, with additional studies identified from a search of reference lists. Only studies involving adult jail or prison populations, with an independent measure of mental illness, were included. Studies in forensic settings to determine fitness to stand trial or criminal responsibility were excluded. Twenty-four studies met all inclusion and exclusion criteria for the review. All articles were coded by two independent authors. Study quality was coded by the lead author., Results: Twenty-two screening tools were identified. Only six tools have replication studies: the Brief Jail Mental Health Screen (BJMHS), the Correctional Mental Health Screen for Men (CMHS-M), the Correctional Mental Health Screen for Women (CMHS-W), the England Mental Health Screen (EMHS), the Jail Screening Assessment Tool (JSAT), and the Referral Decision Scale (RDS). A descriptive summary is provided in lieu of use of meta-analytic techniques due to the lack of replication studies and methodological variations across studies., Conclusions: The BJMHS, CMHS-M, CMHS-W, EMHS and JSAT appear to be the most promising tools. Future research should consider important contextual factors in the implementation of a screening tool that have received little attention. Randomized or quasi-randomized trials are recommended to evaluate the effectiveness of screening to improve the detection of mental illness compared to standard practices.

This paper provides a review of the legislative reforms and case law that have impacted the defense of Not Criminally Responsible on Account of Mental Disorder (NCRMD) in Canada over the past three decades. As in other jurisdictions internationally, we observe that legislative reforms of procedural, as opposed to substantive, aspects of the NCRMD defense have impacted the manner in which NCRMD criteria are applied in common practice. More people are being declared NCRMD in recent years, and there is greater heterogeneity in the offending and psychiatric profiles of these individuals, suggesting that NCRMD criteria are being applied more liberally over time. In light of the substantial growth of the forensic mental health system over the past two decades, witnessed both in Canada and abroad, we propose that the study of motivational influences underlying the offending behaviors of persons with serious mental illness (SMI) is necessary to begin disentangling symptom-based offending from violent and antisocial behaviors that may have other motives. This, in turn, can help to determine legal issues, better define the nature of each person's offending and treatment needs, and provide a more fine-grained analysis of the drivers behind the growth experienced by the forensic system., (Copyright © 2013 John Wiley & Sons, Ltd.)

Background: There are high rates of mental disorder in correctional environments, so effective mental health screening is needed. Implementation of the computerised mental health screen of the Correctional Service of Canada has led to improved identification of offenders with mental health needs but with high rates of false positives., Aims: The goal of this study is to evaluate the use of an iterative classification tree (ICT) approach to mental health screening compared with a simple binary approach using cut-off scores on screening tools., Methods: A total of 504 consecutive admissions to federal prison completed the screen and were also interviewed by a mental health professional. Relationships between screening results and more extended assessment and clinical team discussion were tested., Results: The ICT was more parsimonious in identifying probable 'cases' than standard binary screening. ICT was also highly accurate at detecting mental health needs (AUC=0.87, 95% CI 0.84-0.90). The model identified 118 (23.4%) offenders as likely to need further assessment or treatment, 87% of whom were confirmed cases at clinical interview. Of the 244 (48.4%) offenders who were screened out, only 9% were clinically assessed as requiring further assessment or treatment. Standard binary screening was characterised by more false positives and a comparable false negative rate., Conclusions: The use of ICTs to interpret screening data on the mental health of prisoners needs further evaluation in independent samples in Canada and elsewhere. This first evaluation of the application of such an approach offers the prospect of more effective and efficient use of the scarce resource of mental health services in prisons. Although not required, the use of computers can increase the ease of implementing an ICT model., (Copyright © 2013 John Wiley & Sons, Ltd.)

The number of prison inmates is predicted to rise in Canada, as is concern about those among them with mental illness. This article is a selective literature review of the epidemiology of serious mental illness (SMI) in prisons and how people with SMI respond to imprisonment. We review the required service components with a particular focus on care models for people with SMI in the Canadian correctional system. An estimated 15 to 20 percent of prison inmates have SMI, and this proportion may be increasing. The rate of incarceration of aboriginal people is rising. Although treatment in prison is effective, it is often unavailable or refused. Many of those with SMI are lost to follow-up within months of re-entering the community. There is much policy and service development aimed at improving services in Canada. However, the multijurisdictional organization of health care and the heterogeneity of the SMI population complicate these developments.

Controversy has arisen surrounding findings of not criminally responsible (NCR) or not guilty by reason of insanity (NGRI) in recent years. In some countries, the debate has been driven by the concerns of victims, who are seeking greater information on discharge, accountability on the part of the offender, and involvement in the disposition of NCR or NGRI perpetrators. Their demands raise questions about proportionality between the seriousness of the index offense and the disposition imposed, the place of retribution in the NCR regimen, and the ethics-related challenges that emerge from this tension. We conducted a literature review focused on the relationship of victims to NCR and NGRI processes. The literature is limited. However, theoretical reasoning suggests that interventions based on restorative justice principles reduce persistently negative feelings and increase a sense of justice for victims of criminally responsible defendants. Opportunities and problems with extending such processes into the area of mentally abnormal offenders are discussed.

Objective: To describe pathways taken to care by a sample of patients in a secure forensic unit who have been found not criminally responsible or unfit to stand trial, and to investigate the pathways taken by patients within 3 ethnoracial subgroups of origin: European, African or Caribbean, and Other., Method: Fifty patients from secure forensic units were interviewed using the Encounter Form developed for pathways mapping undertaken in the World Health Organization field trials. Differences in the types of caregivers seen, the total number of caregivers seen, and the time taken to reach forensic psychiatric services were compared across the 3 ethnoracial groupings., Results: Most people committed their index offence after they had already had contact with general mental health services. Few significant differences were observed in the pathways to secure forensic units across the European, African-Caribbean, and Other ethnoracial groups., Conclusions: These findings suggest that improvements in general mental health services may be a key to decreasing the use of forensic psychiatric services. Further research is required to explore factors that may predict and prevent offending. Larger studies are needed to examine ethnoracial differences in pathways to care.

Background: In 2006-2007 New Zealand police deployed the Taser X26 electro-muscular incapacitation device for a twelve month trial across four police districts. Criteria for use of the Taser included "individuals in various states of mental health crisis"., Aims: To provide a descriptive analysis of the use of Tasers by the New Zealand police; to identify those incidents that involved people in mental health emergencies; and to compare this use with that which occurred in incidents of criminal arrest., Method: Descriptive analysis of the police Tactical Operations Database., Results: Tasers were deployed on a total of 141 people in 124 events, and discharged 19 times. Of the 141 subjects, 30 (21%) involved people in mental health emergencies. Tasers were more than twice as likely to be discharged at mental health emergencies (8 of 30; 27%) than at criminal arrests (11 of 111; 10%) (X(2)=5.69; df=1; p=0.017). There were two incidents that involved a Taser being used as part of police response to in-patient mental health services and two incidents involving mental health community residential accommodation., Conclusions: Introduction of Tasers into policing in New Zealand will disproportionately impact on people with mental illness. Guidelines are needed to manage the future use of Tasers in mental health emergencies., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Background: Homicides by people with mental illness have been studied using either clinical or legal categorization of the homicide as abnormal. No previous study has employed both definitions in the same population., Method: A retrospective study of all homicides in New Zealand between 1988 and 2000 considered mentally abnormal homicide using a legal definition (when the courts deemed a contribution of mental illness was present) and a clinical definition (defined as the presence of a discharge diagnosis from inpatient mental health treatment) of 'mentally abnormal'. Rates, characteristics and time trends were investigated., Results: Of the 844 cases, 7.1% met legal criteria for being mentally abnormal, while 7.7% had ever received a diagnosis for a psychotic illness, and a further 14.5% had been admitted to a psychiatric hospital for any other reason. The majority (60%) of perpetrators with a psychotic diagnosis received a mental health disposition from the court. Of these, 60% were first diagnosed with their psychotic illness prior to the homicide, while 28% were first diagnosed at the time of the offence and a further 12% after imprisonment. Of all those who received a psychotic diagnosis, 89% had post-conviction admissions or a mental health disposition., Conclusion: Legal and clinical definitions of mentally abnormal homicide detect similar rates of mentally abnormal homicide, but illustrate somewhat different dimensions of the relationship between mental illness and homicide.

Background: It has been hypothesized that a degree of coercion is a necessary component in using outpatient commitment to attain therapeutic outcome for those people subject to mental health law. However, what degree of coercion is required and how it is sustained is poorly understood. There is speculation that patients' recognition of beneficial as well as unwanted aspects of outpatient commitment (ambivalence) maybe an indicator that the necessary level of coercion has been achieved to facilitate a therapeutic outcome., Aim: The aim of this study was to determine the level of coercion perceived by those under outpatient commitment in New Zealand. Emphasis was given to consideration of the presence of ambivalence and the role of interactive processes, including procedural justice, in influencing patients' perceptions of coercion., Method: A cross-sectional comparative study was undertaken to compare the perceptions of coercion of patients on outpatient commitment (n = 69) to a matched sample of voluntary outpatients (n = 69), using the Perceived Coercion Scale. The influence of a range of variables, including patients' knowledge of and beliefs concerning outpatient commitment, were considered., Results: Although the level of coercion for involuntary outpatients was relatively low, it was significantly higher than that experienced by voluntary outpatients. Yet involuntary outpatients were more likely to espouse benefits of outpatient commitment. Although there was an inverse correlation between perceptions of procedural justice and perceived coercion, procedural justice did not feature in the linear regression analysis., Discussion: In the New Zealand context, involuntary outpatients hold contrasting views to outpatient commitment. We suggest that this ambivalence is an indicator that the degree of coercion is suffice to achieve therapeutic outcome. Furthermore, this study suggests the impact of procedural justice on patients' perceptions of coercion may be more crucial during admission to hospital than in the context of on-going community care.

This paper describes a 7.5 year retrospective study of all patients discharged from inpatient forensic services to forensic community team (FCT) follow-up from the Auckland Regional Forensic Psychiatry Service. Patients' files were studied for clinical, criminal, and risk data, type of service delivered, and final level of function achieved in the community. Rearrest, re-hospitalization, and reimprisonment data were obtained from clinical, court, and prison records.105 patients were included. The most common diagnosis was a psychotic disorder, and index offending behaviour was typically violent. The median period of inpatient stay was 36 months and mean subsequent FCT follow-up 21.7 months (SD 17.8). The majority of patients were from Maori and Pacific Island ethnic groups. At the end of the study, half were in independent living, half were in some form of employment, and 19% were readmitted to a forensic hospital. One patient was rearrested but not reimprisoned whilst under forensic community team care. However, 9 of the 48 who were discharged to general mental health services were rearrested and 5 reimprisoned. Only two offences were as serious as the original index offence. Broad based assertive, mandated, and committed forensic rehabilitation can achieve high quality outcomes. These levels of function may not be sustained under less assertive care., (Copyright 2006 John Wiley & Sons, Ltd.)

Mentally abnormal maternal filicide is a rare and horrifying event. Clinicians are unlikely to develop broad experience with this and there is little information available about recovery. This paper presents a range of descriptions of recovery experiences derived from a qualitative study of mentally abnormal maternal filicide perpetrators. Transcripts from a qualitative, semi-structured interview study of six women who committed filicide in the context of major mental illness were reviewed. Descriptions related to rehabilitation issues were grouped and themes extracted. The women described patchy but horrific memories they avoided thinking and talking about. They described intense self-judgement and self-hate. They valued ongoing relationships with surviving children and were distressed by perceptions that they might be a danger to other children. Managing illness was not described as a major challenge. Acknowledgement of illness was described as important in coming to terms with what they had done. Surviving children and relationships with family and other support networks were described as important in their rehabilitation. We conclude that optimizing treatment and rehabilitation for mental illness, supporting the woman to acknowledge the role of illness in the offence, maximizing support from personal networks, and enabling her to regain some aspect of the mother role may be more efficacious than debriefing with respect to the offence., (Copyright (c) 2006 John Wiley & Sons, Ltd.)