Aims The Independent Forensic Mental Health Review (Scottish Government, 2021) highlighted an issue with timely transitions through and out of Scottish forensic inpatient services. Concerns were raised regarding the impact of transfer and discharge delays upon patients. As part of a wider service evaluation examining the pathways forensic mental health patients navigated through secure inpatient care, this study aimed to identify the requirements, processes and time-frames involved in transfer from The State Hospital (TSH), which provides male only, high secure care to Scotland and Northern Ireland. Methods Data for 69 patients noted on TSH transfer list (2017–2019) were collected. In addition to patient demographic, clinical and forensic variables, data was gathered about use of appeals against excessive security under section 264 and 265 of the Mental Health (Care and Treatment) (Scotland) Act 2003. Results Forty-nine (71.0%) patients were referred to medium secure care, 6 (12.2%) to low secure care and 14 (20.3%) for return to prison. Schizophrenia was the most common primary diagnosis (43, 62.3%), with 75.5% (37) of those referred to medium secure care vs 21.4% (3) returning to prison having received this diagnosis. There were statistically significant associations in terms of time between referral and transfer between individuals who had a primary diagnosis of Schizophrenia/Schizoaffective disorder (no 114, yes 388.5 days; Median) and whether they had lodged a section 264 appeal (no 109.5, yes 469.0 days; Median) or section 265 appeal (no 134.5, yes 517.0 days; Median) against excessive security. There were no significant differences in days from referral to transfer/discharge based on behaviour leading to admission or the number of formal attempts to transfer during current admission. Twenty (40.8%) patients referred to medium secure services made a successful section 265 appeal which resulted in a ruling that they should be transferred within three months. Seven (35%) of these patients were transferred inside three months. Conclusion Patients are waiting significantly variable lengths of time from referral to transfer depending on the service they are being referred to. The use of section 264 and 265 appeals against excessive security was implicated in a greatly increased length of time to transfer. Patients considered to have the most serious chronic mental health conditions are waiting the longest time for transfer with potential implications for their mental health. Patients’ human rights are potentially affected due to continuing to be placed in conditions of excessive security for more than a year following decision to refer.

BackgroundThis study examined the outcomes of a descriptive, longitudinal cohort consisting of 241 patients initially examined in a population study at the high secure State Hospital for Scotland and Northern Ireland in 1992–93. A partial follow-up focusing on patients with schizophrenia was conducted in 2000–01, followed by a comprehensive 20 year follow-up that began in 2014.AimsTo explore what happens to patients who required high secure care during a 20 year follow-up period.MethodPreviously collected data were amalgamated with newly collected information to examine the recovery journey since baseline. Various sources were employed, including patient and keyworker interviews, case note reviews, and extraction from health and national records, and Police Scotland datasets.ResultsOver half of the cohort (56.0%) with available data resided outside secure services at some point during the follow-up period (mean 19.2 years), and only 12% of the cohort were unable to transition out of high secure care. The symptoms of psychosis improved, with statistically significant reductions observed in reported delusions, depression, and flattened affect. Reported sadness [according to the Montgomery–Åsberg Depression Rating Scale (MADRS)] at baseline, first, and 20 year follow-up interviews was negatively correlated with the questionnaire about the process of recovery (QPR) scores at the 20 year follow-up. However, qualitative data depicted progress and personal development. According to societal measures, there was little evidence of sustained social or functional recovery. The overall conviction rate post-baseline was 22.7%, with 7.9% violent recidivism. The cohort exhibited poor morbidity and mortality, with 36.9% of the cohort dying, primarily from natural causes (91%).ConclusionsOverall, the findings showed positive outcomes in terms of movement out of high-security settings, symptom improvement, and low levels of recidivism. Notably, this cohort experienced a high rate of deaths and poor physical morbidity, along with a lack of sustained social recovery, particularly among those who had negotiated a path through services and who were current residents in the community. Social engagement, enhanced during residence in low secure or open ward settings, diminished significantly during the transition to the community. This is likely a result of self-protective measures adopted to mitigate societal stigma and the shift from a communal environment. Subjective depressive symptoms may impact broader aspects of recovery.

IntroductionThis study reports on an assessment of mental health needs among Scotland's prison population which aimed to describe the scale and nature of need as well as identify opportunities to improve upon the services available. The project was commissioned by the Scottish Government to ensure that future changes to the services available to support the mental health and wellbeing of people in prison would be evidence-based and person-centered.MethodsA standardized approach to health needs assessments was employed. The study was comprised of four phases. In phase I a rapid literature review was undertaken to gather evidence on the prevalence of mental health needs experienced by people in prison in the UK. In Phase II a multi-method and multi-informant national mapping exercise involving providers to all Scottish prisons was undertaken to describe the mental health services available, and any gaps in these services, for people in and leaving prison. In Phase III prevalence estimates of several mental health needs were derived for Scotland's current prison population, modeled from a national survey dataset of Scotland's community population using logistic regression. Finally in Phase IV, professional stakeholders and individuals with lived experience were interviewed to understand their experiences and insights on challenges to supporting the mental health and wellbeing of people in prison, and ideas on how these challenges could be overcome.ResultsEvidence across the four phases of this needs assessment converged indicating that existing provision to support the mental health of people in prison in Scotland was considered inadequate to meet these needs. Barriers to effective partnership working for justice, health, social work and third sector providers appear to have led to inadequate and fragmented care, leaving prisoners without the support they need during and immediately following imprisonment.ConclusionsJoint and coordinated action from justice, health and social care, and third sector providers is needed to overcome enduring and structural challenges to supporting the mental health of people in prison. Eighteen evidence-based recommendations were proposed to the Scottish Government relating to the high-level and operational-level changes required to adequately meet the prison population's mental health needs.

BACKGROUND:Premature mortality among patients experiencing forensic care is high. This paper examines the morbidity and mortality of all Scottish high secure patients in 1992/1993 and followed up 20 years later through the context of recovery.AIMS:To explore morbidity and delineate which patients are at greatest risk of premature mortality. To assess the extent of suicide and unnatural deaths. To establish which factors, if any, appear protective.METHOD:Health and mortality data were extracted from national data-sets and death categorised as premature or post-expected age. Standardised mortality ratios were calculated to explore natural, unnatural and suicide deaths with Cox regression conducted to explore baseline demographics and premature death.RESULTS:During a mean follow-up of 21.1 years, 36.9% (n = 89) died, at an average age of 55.6 years. Of these, 70.8% (n = 63) died prematurely. Men lost on average 14.9 years and women 24.1 years of potential life. Five lives (5.6%) were lost by suicide and three (3.4%) by unnatural means.CONCLUSIONS:In contrast to other mainstream and forensic cohorts, high rates of suicide and accidental deaths were not apparent. Risk of premature mortality is high. A greater focus upon physical health by community and in-patient services is essential.

A person‐centred approach to recovery is increasingly represented within mainstream mental health literature. Little examination of recovery among forensic mental health patients is evidenced. This study plans to address that insufficiency.

The irrefutable consequence of Scottish excessive alcohol consumption has prompted implementation and proposal of alcohol policy measures. The purpose of this study is to explore with heavy drinkers their awareness of and identify potential implications of policy introducing alcohol minimum unit pricing (MUP). Face-to-face semi-structured interviews were conducted with drinkers with alcohol-related harm (n = 20; 15 males, five females; aged 34 to 67 years old) in Scotland's two largest cities (drinkers were participants within a larger quantitative study, through attendance for treatment for alcohol-related harms at National Health Service [NHS] centers). Median weekly consumption among participants was 130.7 units (range: 28-256.3 U.K. units). Views regarding the impact of increased alcohol prices, through MUP, were mixed. While some drinkers indicated potential reduction in intake, thus possibly reducing alcohol harms in the long term, the expected, or even desired, from a public health perspective, effects on consumption and associated harms might not be fully realized in this group. To mitigate possible unintended short-term detrimental effects of MUP on the most vulnerable, careful planning and appropriate resourcing may be required prior to implementation.

Background/aims: An appreciation of the drinking patterns of population subgroups may usefully inform tailored interventions. For this purpose, research has highlighted a need to better describe the drinking behaviour of UK women. This study aims to characterise the purchasing and consumption behaviour of female heavy, harmed, drinkers in contact with Scottish health services in two cities and to explore the factors that influence the link to harm. Methods: Mixed methods study involving cross-sectional survey questionnaires and one-to-one interviews (5). The questionnaires documented (1) demographic data (including derived deprivation score), last week’s (or ‘typical’ weekly) consumption (type, brand, volume, price, place of purchase), self-reported illnesses, and (2) Alcohol-Related Problem Questionnaire score. A total of 181 patients with serious health problems linked to alcohol were recruited within National Health Service (NHS) hospital clinics (in- and outpatient settings), in two Scottish cities during 2012. Results: Median consumption was 157.6 UK units for the recorded week, with almost exclusive purchase from ‘off-sale’ retail outlets. Preferred drinks were white cider, vodka and white wine. Increasing problems was positively associated with drinking more in the week, being younger and belonging to Glasgow. Conclusion: For Scottish women, the current definition of ‘harmful’ consumption likely captures a fourfold variation in alcohol intake, with gender differences less apparent. While current alcohol-related harm is positively associated with dose and being younger, there is clear evidence of an influence of the less tangible ‘Glasgow effect’. Future harm concerns are warranted by data relating to pattern, alcohol dose and cigarette use.

Background Considerable challenges exist for researchers attempting to monitor longitudinally the impact of any intervention on heavy drinkers, therefore they are often excluded from surveys. A particular challenge is the loss of validity through attrition. Aim To describe issues encountered when recruiting and re-contacting difficult to reach heavy drinkers participating in a longitudinal study; and propose strategies to inform the design of future studies to minimise the effects of confounding factors. Discussion Baseline recruitment exceeded targets, but attrition at first follow-up interview was considerable. Baseline alcohol consumption was not predictive of loss to follow-up. A variety of factors affected attrition including abstinence, severe intoxication at interview, deaths, selling of telephone, change of address and incarceration. Conclusion Longitudinal studies that use personal telephones or address details in following up heavy drinkers face considerable challenges to minimise attrition. An important mitigating factor is the use of flexible and experienced interviewers. Implications for practice The anticipated and reactive strategies documented in this paper provide important lessons for costing, designing and collecting data in future studies.

Background: Alcohol consumption has posed well-documented problems for Scottish society in terms of morbidity, mortality, and wider societal costs. Objectives: To investigate the lived experiences and drinking behaviors of people with alcohol-related harm in Scotland against a backdrop of recent economic downturn, falling incomes, welfare reform, and changes to state benefits. Methods: As part of a larger Scottish study (2012-2014) of 639 individuals attending hospital or admitted, relating to an alcohol problem, 20 participants completed semistructured interviews about their drinking and purchasing habits that were subjected to thematic analysis. Conclusions: Key themes elucidated participants' everyday drink-related behaviors within their local environment including drinking triggers, sourcing alcohol, resourcing alcohol purchase, and views relating to substitution. The majority of participants had experienced reduced income and adapted their alcohol-purchasing behaviors accordingly, including trading down to cheaper alcohol. A reduction in food purchasing and heating was a common outcome, as was falling into, or increasing current, debt. More attention should be paid to the prevalence and accessibility of alcohol within local communities. Ultimately, as long as there is highly visible and easily accessible cheap alcohol, heavy drinkers may struggle to undertake positive steps to reduce their damaging consumption levels.

The perceived value of Alcohol Brief Interventions as a tool to address alcohol misuse in Scotland has supported the establishment of a Health Improvement, Efficiency, Access and Treatment, HEAT: H4 Standard to deliver ABIs within certain health care settings. This requires that nursing, medical and allied health professionals are appropriately skilled to deliver these interventions. This study explores the knowledge and attitudes regarding alcohol misuse and related interventions among two cohorts of final year nursing and occupational therapy undergraduate students before, during and following participation in a workshop devoted to ABI delivery. While relatively good knowledge around recommended limits for daily consumption was evident, this did not translate into competence relating to drink unit content. Although there was overwhelming agreement for the role of each profession in ABI delivery, less than half of students in each cohort at the outset of the workshop agreed that they had the appropriate knowledge to advise patients about responsible drinking. In both cohorts, at the three month follow-up stage, this percentage had almost doubled. Newly qualified practitioners perceived a wider role for motivational interviewing, and endorsed interactive delivery of alcohol education throughout all levels of the curriculum.

Aims: To compare characteristics of heavy drinkers who do, or do not, drink white cider during their typical drinking week and to contrast white cider drinkers' behaviour with a similar group recruited in comparable settings 4 years previously. To consider if excessive white cider consumption poses a specific health risk. Methods: Cross-sectional survey of alcohol purchasing and consumption by heavy drinkers consuming white cider in Edinburgh and Glasgow during 2012; comparison of purchasing patterns within Edinburgh in 2008-2009 and 2012. Participants were 639 patients (in-and out-patient settings) with serious health problems linked to alcohol, 345 in Glasgow, 294 in Edinburgh in 2012, and 377 in Edinburgh in 2008-2009. Results: In 2012 white cider consumption was reported by 25% of participants (median consumption (all alcohol) was 249 UK units per week-1 UK unit being 8 g of ethanol). They were more likely to be male and younger. They drank more units of alcohol than non-white cider drinkers and reported more alcohol-related problems. The median price paid for white cider in 2012 was 17 ppu. The period 2008-2012 was associated with decreasing affordability of alcohol, but consumption levels amongst the heaviest drinkers were maintained, associated with an increased proportion of units purchased as white cider. Conclusion: White cider makes an important contribution to the weekly intake of heavy drinkers in Scotland, likely facilitated by low price per unit of alcohol. We suggest these characteristics permit this drink to act as a buffer, supporting the continuation of a heavy drinking pattern when affordability of alcohol falls.

AIMS To compare characteristics of heavy drinkers who do, or do not, drink white cider during their typical drinking week and to contrast white cider drinkers' behaviour with a similar group recruited in comparable settings 4 years previously. To consider if excessive white cider consumption poses a specific health risk. METHODS Cross-sectional survey of alcohol purchasing and consumption by heavy drinkers consuming white cider in Edinburgh and Glasgow during 2012; comparison of purchasing patterns within Edinburgh in 2008-2009 and 2012. Participants were 639 patients (in- and out-patient settings) with serious health problems linked to alcohol, 345 in Glasgow, 294 in Edinburgh in 2012, and 377 in Edinburgh in 2008-2009. RESULTS In 2012 white cider consumption was reported by 25% of participants (median consumption (all alcohol) was 249 UK units per week-1 UK unit being 8 g of ethanol). They were more likely to be male and younger. They drank more units of alcohol than non-white cider drinkers and reported more alcohol-related problems. The median price paid for white cider in 2012 was 17 ppu. The period 2008-2012 was associated with decreasing affordability of alcohol, but consumption levels amongst the heaviest drinkers were maintained, associated with an increased proportion of units purchased as white cider. CONCLUSION White cider makes an important contribution to the weekly intake of heavy drinkers in Scotland, likely facilitated by low price per unit of alcohol. We suggest these characteristics permit this drink to act as a buffer, supporting the continuation of a heavy drinking pattern when affordability of alcohol falls.