Aims: Erotomanic delusions involve the fixed false belief that another person (often of higher social status) is in love with the individual. Although rare, erotomania is clinically significant due to its association with stalking, harassment, and, in some cases, serious violence. Risk assessment framework deficits have contributed to fragmented understanding of factors associated with violent escalation. Existing evidence is largely confined to case reports and case series, limiting systematic synthesis of clinical and contextual risk factors. This scoping review aimed to synthesise published case-level evidence on erotomania associated with stalking and/or violent behaviour. The primary objective was to identify individual, clinical, and contextual factors linked to stalking or violence in people with erotomanic delusions. Secondary objectives were to describe the nature and severity of violence and to identify gaps in the literature. Methods: A literature search was conducted in January 2026 using six databases. Eligible publications included case reports, case series, and observational or qualitative studies describing erotomanic delusions in connection with stalking or violence. Data were extracted using Covidence capturing sociodemographic, clinical and criminological factors. Results were synthesised descriptively and reported as frequencies and percentages overall and by sex. Fifty publications comprising 87 cases were included. Results: The sample included 51 males (58.6%) and 36 females (41.4%), with a mean age of 36.0 years (SD 11.7). Most individuals were single, socially isolated and had unstable living arrangements. Erotomanic delusions were most commonly described in the context of a primary diagnosis of a psychotic illness (90.8%). Co-occurring delusional themes were common, particularly referential, persecutory, and grandiose delusions. Stalking was reported in 88.5% of cases, typically involving a single object. Victims were predominantly female (64.5%) and most often professionals (e.g. clinicians, employers). Violence occurred in 49.4% of cases, with males significantly more likely to perpetrate severe violence. Common motivations included delusional beliefs of reciprocated love and perceived rejection. Criminal charges arose in over half of cases, particularly among male offenders. Conclusion: Erotomania associated with stalking and violence represents a high-risk clinical and forensic phenomenon. The literature remains dominated by descriptive reports underscoring the need for structured risk assessment approaches, clearer diagnostic guidance, and targeted management strategies to prevent escalation and harm.

Background In-patient mental health rehabilitation services provide specialist care to adults with complex psychosis. In England, there are more than 350 such services, half provided by the National Health Service (NHS) and half by the independent sector. Aims To investigate whether NHS and independent sector in-patient mental health rehabilitation services differ. Method We recruited a random sample of NHS and independent sector services across England. We collected cross-sectional data regarding service and patient characteristics through interviews with patients, clinicians and managers, and from healthcare record reviews. Results We recruited 411 patients from 48 NHS services and 172 patients from 20 independent sector services. Service characteristics, including standardised quality scores, were similar. Most patients had a diagnosis of schizophrenia (NHS n = 237, 57.7%; independent sector n = 99, 57.6%) or schizoaffective disorder (NHS n = 88, 21.4%; independent sector n = 32, 18.6%). More than half had at least one comorbid condition, but more independent sector patients had at least two (NHS 131 of 411, 31.9%; independent sector 80 of 172, 46.5%; P = 0.001). Current admissions were twice as long for independent sector patients (NHS mean 1.2 years [s.d. 1.5]; independent sector mean 2.4 years [s.d. 2.8]). Standardised ratings of patients’ quality of life, autonomy, time use, satisfaction with care, social and everyday functioning, and challenging behaviours were similar. However, independent sector patients had more needs (NHS mean 6.5 [s.d. 3.2]; independent sector mean 7.9 [s.d. 3.9]; P < 0.001) and more had a history of fire setting (NHS 32, 7.9%; independent sector 28, 17.2%; P = 0.001). Conclusions Both NHS and independent sector in-patient rehabilitation services support people with complex psychosis, but independent sector patients may have more complex conditions, which could explain their longer admissions.

Aims: Delusional misidentification syndromes (DMS) are characterised by a delusional belief of misidentification concerning familiar individuals, places or objects and by the conviction that they have been replaced or transformed. Violent behaviours towards the “impostor” are often observed and can take the form of verbal threats or physical assault. This review explores the specific factors that increase the risk of violence in individuals with DMS.

Background Mental health rehabilitation services provide specialist treatment to people with particularly severe and complex problems. In 2018, the Care Quality Commission reported that over half the 4,400 mental health inpatient rehabilitation beds in England were provided by the independent sector. They raised concerns that the length of stay and cost of independent sector care was double that of the NHS and that their services tended to be provided much further from people’s homes. However, there has been no research comparing the two sectors and we therefore do not know if these concerns are justified. The ACER Study (Assessing the Clinical and cost-Effectiveness of inpatient mental health Rehabilitation services provided by the NHS and independent sector) is a national programme of research in England, funded from 2021 to 2026, that aims to investigate differences in inpatient mental health rehabilitation provided by the NHS and independent sector in terms of: patient characteristics; service quality; patient, carer and staff experiences; clinical and cost effectiveness. Methods ACER comprises a:1) detailed survey of NHS and independent sector inpatient mental health rehabilitation services across England; 2) qualitative investigation of patient, family, staff and commissioners’ experiences of the two sectors; 3) cohort study comparing clinical outcomes in the two sectors over 18 months; 4) comprehensive national comparison of inpatient service use in the two sectors, using instrumental variable analysis of routinely collected healthcare data over 18 months; 5) health economic evaluation of the relative cost-effectiveness of the two sectors. In Components 3 and 4, our primary outcome is ‘successful rehabilitation’ defined as a) being discharged from the inpatient rehabilitation unit without readmission and b) inpatient service use over the 18 months. Discussion The ACER study will deliver the first empirical comparison of the clinical and cost-effectiveness of NHS and independent sector inpatient mental health rehabilitation services. Trial registration ISRCTN17381762 retrospectively registered.

IntroductionPatients with psychosis can develop sexual dysfunction, which may be related to the disease itself, psychosocial factors, somatic comorbidities, and the use of psychotropic medication.ObjectiveWe aimed to investigate the type and frequency of sexual dysfunction in patients diagnosed with schizophrenia or bipolar disorder in order to assess the side effects of antipsychotics in sexual function.MethodsThis is a multicenter, cross-sectional study, involving patients diagnosed with schizophrenia (79.3%) or bipolar disorder (20.7%) treated in the Department of Psychiatry and Community Mental Health Centers from November 2018 to December 2019. Patients were enrolled in the study after signed informed consent. Demographic and clinical data were collected from patients through a semi-structured interview. The Antipsychotics and Sexual Functioning Questionnaire (ASFQ) was administered to assess sexual function.ResultsA total of 87 outpatients on antipsychotics were recruited in the study. The mean age was 43.6 years, while the mean duration of the disease was 16.9 years. Overall, only 9.1% of patients spontaneously reported sexual dysfunction. Patients treated with oral first-generation antipsychotics had more difficulties in achieving orgasm and decreased erection capacity. In contrast, patients treated with oral second-generation antipsychotics had decreased ejaculation capacity. Patients on antipsychotic combination therapy were associated with higher rates of sexual anhedonia.DiscussionThese results suggest that sexual dysfunction is a side effect of antipsychotic treatment, which was spontaneously rarely reported by patients. It seems essential to obtain a psychosexual clinical history before initiating antipsychotic treatment to evaluate following changes and adopt an individualized strategy to manage sexual dysfunction induced by antipsychotics.

Introduction: Sexual dysfunction in patients with psychoses may be associated with the psychiatric illness itself (negative symptoms, such as apathy, and avolition), comorbid somatic health, psychosocial factors (stigmatization, discrimination), and the use of psychotropic drugs. In Greece, research into the study of antipsychoticinduced sexual dysfunction is not sufficient. Aim: This study was conducted to translate and validate the Greek version of the Antipsychotics and Sexual Functioning Questionnaire (ASFQ) in a sample of patients receiving antipsychotic treatment. Methods: A "forward-backward translation" method was applied. A pilot study was conducted with 15 outpatients with schizophrenia and bipolar disorder under antipsychotics treatment. Patients also completed the "Subjects' Response to Antipsychotics (SRA)" questionnaire in order to assess the validity of the ASFQ. The ASFQ and the SRA questionnaire were completed twice within 2 weeks. Main outcome measures: Reliability (internal consistency and test-retest) and validity were assessed. Results: The Greek translation of ASFQ was reliable, with excellent internal consistency (Cronbach's a = 0.90 formen and 0.95 for women in both measurements). In addition, the Spearman correlation coefficient was 1 (P<.001) in all Likert-type questions in both assessments. Finally, Spearman correlation coefficients between ASFQ and SRA were moderately positive to strongly positive (between 0.25 and 1) in both assessments, demonstrating moderate to high validity. Conclusions: The Greek version of the ASFQ has proved to be a reliable and valid clinical instrument, hence it can be used in further studies in the Greek population. Copyright (C) 2021 The Authors. Published by Elsevier Inc. on behalf of the International Society for Sexual Medicine.

The study explored health related quality of life of prisoners with diabetes mellitus (DM).48 male inmates incarcerated in a Greek prison, completed a demographic and clinical traits questionnaire. Prisoners with DM and those with additional health problems had worse physical, mental health and psychological well-being outcomes (p = 0.002, p < 0.001 and p = 0.014 respectively). People with DM in correctional facilities should receive specialized primary health care services either health services within the correctional institution or community liaison. The implementation of services targeting DM should be evaluated with the target of improving offenders' physical and mental health.

In England, community mental health rehabilitation teams play a major role in supporting people with complex mental health needs to progress from inpatient to community settings and from more to less supported accommodation. We aimed to conduct the first study to investigate longitudinal outcomes for users of a community rehabilitation team and identify service user characteristics associated with successful progress along the rehabilitation pathway. We used routinely collected clinical outcome data relating to all 193 users of a community rehabilitation team in inner London, transferred to the team between June 2013 and May 2018, with a cut-off data-collection date of 20th June 2019. We estimated the proportion who moved on to more independent accommodation successfully, with no breakdown in the placement. We conducted multivariable Cox proportional hazard regression to investigate associations between service user characteristics at transfer and successful move-on. Overall, 43/193 (23%) service users achieved successful move-on during a median follow-up of 51 months (IQR 32–63). This was more likely for those who were residing in more highly supported accommodation (HR 3.90; 95% CI 2.01–7.54) and those who had better functioning (HR 1.04, 95% CI 1.02–1.06) at transfer, while those with a serious physical health condition were less likely to achieve successful move-on (HR 0.44, 95% CI 0.21–0.95). Most supported accommodation services aim to offer time-limited support, but most service users do not progress successfully to more independent accommodation within 4 years. Investment in interventions that improve functioning and physical health may facilitate successful move-on.

With research showing a high prevalence of psychosis in prisons, its effective management is essential for clinical and criminal outcomes. In a matched sample of released prisoners and discharged patients with psychosis (124 pairs) we investigated whether group participation (prison vs. hospital) affected the likelihood of reoffending as well as time to reoffending. Statistical analysis was completed using multilevel logistic regression and multilevel survival analysis. We found that prison cases were more likely to commit any offence within a given period of time (1, 2 or 3 years). Moreover, at any particular time 3 times as many patients with psychosis released from prisons reoffended proportionally to their matched controls discharged from hospitals (HR = 2.92, 95% CI = 1.99, 4.29, P < 0.001). In conclusion, release from prison carries higher risk of a future offending and reduced time to reoffending among offenders with psychosis. Notwithstanding limitations inherent in observational study designs, we advocate that in addition to clinical need and the humanitarian argument, offenders with psychosis should be treated in secure hospitals to reduce future recidivism.

Background: Identification of biomarkers predicting therapeutic outcome of antidepressant treatment is one of the most important tasks in current research because it may transform the lengthy process of finding the right treatment for a given individual with depression. In the current study, we explored the potential of pretreatment pregenual anterior cingulate cortex activity as a putative biomarker of treatment response. Methods: Thirty-two medication-free patients with depression were treated for 6 weeks with a selective serotonin reuptake inhibitor, escitalopram. Before treatment began, patients underwent an fMRI scan testing response to brief, masked, presentations of facial expression depicting sadness and happiness. Results: After 6 weeks of treatment, there were 20 selective serotonin reuptake inhibitor responders and 12 nonresponders. Increased pretreatment pregenual anterior cingulate cortex activity to sad vs happy faces was observed in responders relative to nonresponders. A leave-one-out analysis suggested that activity in the anterior cingulate cortex was able to predict response status at the level of the individual participant. Conclusions: The study supports the notion of pregenual anterior cingulate cortex as a promising predictor of antidepressant response.

BACKGROUND AND AIMS:Violent behaviour by forensic psychiatric inpatients is common. We aimed to systematically review the performance of structured risk assessment tools for violence in these settings. METHODS:The nine most commonly used violence risk assessment instruments used in psychiatric hospitals were examined. A systematic search of five databases (CINAHL, Embase, Global Health, PsycINFO and PubMed) was conducted to identify studies examining the predictive accuracy of these tools in forensic psychiatric inpatient settings. Risk assessment instruments were separated into those designed for imminent (within 24 hours) violence prediction and those designed for longer-term prediction. A range of accuracy measures and descriptive variables were extracted. A quality assessment was performed for each eligible study using the QUADAS-2. Summary performance measures (sensitivity, specificity, positive and negative predictive values, diagnostic odds ratio, and area under the curve value) and HSROC curves were produced. In addition, meta-regression analyses investigated study and sample effects on tool performance. RESULTS:Fifty-two eligible publications were identified, of which 43 provided information on tool accuracy in the form of AUC statistics. These provided data on 78 individual samples, with information on 6,840 patients. Of these, 35 samples (3,306 patients from 19 publications) provided data on all performance measures. The median AUC value for the wider group of 78 samples was higher for imminent tools (AUC 0.83; IQR: 0.71-0.85) compared with longer-term tools (AUC 0.68; IQR: 0.62-0.75). Other performance measures indicated variable accuracy for imminent and longer-term tools. Meta-regression indicated that no study or sample-related characteristics were associated with between-study differences in AUCs. INTERPRETATION:The performance of current tools in predicting risk of violence beyond the first few days is variable, and the selection of which tool to use in clinical practice should consider accuracy estimates. For more imminent violence, however, there is evidence in support of brief scalable assessment tools.

Psychopathy consists of a constellation of affective-interpersonal features including lack of empathy, callousness, manipulativeness and interpersonal charm, impulsiveness and irresponsibility. Despite its theoretical and predictive value in forensic contexts, the relationships between the psychometric dimensions of psychopathy, including its antisocial features, and the construct's neuropsychological characteristics remain uncertain. In this study, 685 personality-disordered prisoners with histories of serious violent or sexual offenses were assessed for psychopathy before completing a computerized and well-validated assessment of the ability to recognize emotional expressions in the face. Prisoners with more of the affective features of psychopathy, and prisoners with more of its antisocial manifestations, showed relatively poor recognition accuracy of fearfulness and disgust. These relationships were independent and modest but were still evident following correction for demographic features (e.g., ethnicity and socioeconomic status), mental illness (e.g., substance and alcohol misuse), personality disorders (other than antisocial personality disorder) and treatment status. By contrast, the associations between these dimensions of psychopathy and emotion recognition were diminished by controlling for cognitive ability. These findings demonstrate that variability in the ability of high-risk personality-disordered prisoners to recognize emotional expressions in the face-in particular, fear and disgust-reflects both the affective and antisocial aspects of psychopathy, and is moderated by cognitive ability.

In 1997 shootings in schools were recognized as a social problem, especially after the Columbine shootings in 1999 [1]. From 2001 to 2006 their publicity has been reduced, something that it is hypothesized to have changed after the Virginia Tech shootings in 2007 [2]. These attacks have been described as an “epidemic”, since six incidents happened in a small period of time, in the years 1997 to 1998 [3]. Criminologists considered these shootings as the new type of youth violence [4]. Statistically offenders younger than 18 years old commit 10.9% of the total homicides and 9.5% of the multiple homicides [5]. Despite these small percentages the mean offender age has dropped. As the FBI points out, since mass murder is a rare phenomenon even few incidents can influence the average age [6]. Schools are the forth most likely location for a mass murder to happen (9.7%) [6]. School-associated homicides represent less than 1% of the total homicides [7-9] despite the fact that the homicides with multiple victims have risen from 0% in 1992 to 42% in 1999 [7].

The search for treatment biomarkers is an important practical task, as current treatments are still ‘trial and error’, and clinical response can be assessed after weeks only. The aim of this study was to explore differential neural activation to emotional information presented below the conscious awareness level, and its prospective value in predicting response to antidepressant treatment.

Purpose The purpose of this paper is to investigate the prevalence of stress and burnout among forensic mental health (FMH) professionals. Design/methodology/approach A systematic review of the available literature accessed by relevant databases was conducted. Findings This study concluded that FMH suffer from moderate levels of both stress and burnout. There is insufficient evidence to establish that they suffer from higher levels of stress than their non-forensic colleagues. Interventions such as psychosocial intervention training have been reported to demonstrate an improvement in staff knowledge and attitudes towards patients, whilst reducing burnout. Practical implications Stress in FMH is a cause of concern. Conclusions drawn are applicable only to nursing staff as other professions were not adequately represented. As most studies used the burnout scores, results were directly comparable. Further research is needed to fully evaluate stress and burnout in professionals who work within FMH settings. Originality/value High levels of stress and burnout have negative effects on an individual’s ability to work and subsequently there is a financial and also moral incentive for the management of health service workforces to intervene. This study highlights that FMH, as a population, are at risk.