Aims and method Community forensic mental health services (CFMHS) in England were developed to reduce reliance on hospital care for this population, but provision varies. It is unclear whether standard setting work has increased consistency. Freedom of information requests were therefore sent to 50 National Health Service Trusts in England, to examine the population, staffing, treatment provision and organisation of CFMHS. Results Data were provided for 32 CFMHS, of which 59% were part of secure hospital-based services and 41% were standalone services working in parallel with general services. There was variation in aspects including professional composition, functions, the settings from where CFMHS accept referrals and long-term approach to patients subject to special restrictions under the Mental Health Act 1983. Clinical implications CFMHS continue to vary, especially in their interface with services other than forensic hospitals. This may impede standard setting and empirical evaluation. Different approaches to centralising oversight may be needed for standardisation.

BACKGROUND:Patients with traumatic brain injury (TBI) are at a greater risk of subsequent violent victimisation, and a prognostic model can assist in identifying those at highest risk who can benefit from targeted interventions. We aimed to develop and internally validate a clinical prediction model to estimate the risk of violent victimisation following TBI in adolescence. METHODS:We investigated a cohort of adolescents aged 10 to 24 exposed to TBI between 2009 and 2023, using data from a linked register, covering 86% of the population in Wales, the Secure Anonymised Information Linkage (SAIL) Databank. We fitted a multivariable Cox regression model for the association between predictors and time to violent victimisation identified in medical records, with optimism-corrected bootstrapping for internal validation. Key performance measures, including discrimination and calibration, were examined at 1 and 3 years post-TBI. RESULTS:The cohort included 34 092 adolescents, of whom 332 (1.0%) were violently victimised within 1 year and 701 (2.1%) within 3 years of the TBI. The final model included a range of predictors including calendar age, sex at birth, substance misuse, psychiatric conditions, neurological conditions, conduct disorder, learning difficulties and a history of victimisation or self-harm. The clinical prediction model showed good calibration and moderate discrimination at 1 (area under the curve (AUC)=0.72) and 3 years (AUC=0.67) post-TBI. DISCUSSION:This brief, scalable and evidence-based prediction model showed moderate predictive performance at internal validation. External validation is necessary to test the model's transportability. CONCLUSIONS:A large population-based sample was used to identify risk factors for violent victimisation and develop a novel clinical prediction model for use in adolescents with TBI.

PURPOSE:Vitamin D deficiency is a global concern, disproportionately affecting vulnerable populations, including prisoners. Vitamin D was found to be protective against Covid-19 during the pandemic. As a response, Nottinghamshire Healthcare NHS Foundation Trust implemented a vitamin D supplementation policy across three prison health-care settings in the UK. The purpose of this study was to assess the overall impact of this policy on supplementation rates and Vitamin D deficiency. DESIGN/METHODOLOGY/APPROACH:This pragmatic cross-sectional study retrospectively evaluated the impact of the vitamin D supplementation policy on supplementation uptake and deficiency rates. Vitamin D deficiency was defined as less than 50 nmol/L. Cross-sectional data were collected from 768 prisoners for periods of two years before and two years after introduction of the policy. FINDINGS:Overall supplementation rates were lower after the policy introduction (43%, n = 330 versus 35%, n = 270; McNemar's χ2, p = 0.004). However, there was increased uptake among previously untreated individuals - 40% (n = 175) of those previously untreated (n = 438) received supplementation after policy implementation. There was an overall reduction in vitamin D deficiency from 71% to 55% after policy introduction (χ2 = 12.3, Cramer's V = 0.13, p < 0.001). Mean vitamin D levels increased from 41.3 nmol/L to 50.3 nmol/L. In a small subsample (n = 23) in whom vitamin D levels were available before and after the policy, paired sample analysis showed significant mean vitamin D level increase (p < 0.001). An exploratory analysis using binary logistic regression suggested the specific prison location and pre-existing vitamin D deficiency as significant predictors of deficiency post-policy. ORIGINALITY/VALUE:The findings highlight the potential effectiveness of a simple, population-wide supplementation strategy in reducing vitamin D deficiency within prisons. Future research should use prospective designs and explore factors influencing supplementation adherence and long-term health outcomes, toward developing the most effective strategies.

Introduction Secure mental health pathways are complex. They are typically based around secure hospitals, but also interface with justice agencies and other clinical services, including in the community. Consideration of risk is fundamental to clinical care and to decisions relating to a patient’s stepwise journey through the pathway. Patient autonomy and involvement in decision-making are policy priorities for health services. However, improving collaboration in risk-related decisions in secure services is complicated by potential issues with insight and capacity and the necessary involvement of other agencies. In addition, although some collaborative approaches are feasible and effective, their impact, mechanisms and the contexts in which they work are not well understood. Therefore, using realist methodology, this review will outline what works, for whom, why and under what circumstances in terms of collaborative risk assessment and management in secure services.Methods and analysis The review will consist of four stages: (1) Development of an initial programme theory to explain how and why collaborative risk assessment and management works for different groups of people, (2) search for evidence, (3) data selection and extraction and (4) evidence synthesis and development of a final programme theory. Our initial programme theory will be informed by an informal search of the literature and consultation with experts and patient and public involvement and engagement representatives. Following this, our formal literature search will include both the published and unpublished literature. During full text screening, each document will be assessed according to the principles of rigour and relevance and, if included, data will be extracted and synthesised to refine the programme theory.Ethics and dissemination This protocol is for a review of published literature and so does not require ethical approval. The main output will be the final programme theory. Remaining gaps will inform planned future work to further refine the theory using mixed methods. Our dissemination strategy will be codeveloped with our public and patient involvement group and will include publishing findings in a peer-reviewed journal and presenting findings at relevant professional conferences, as well as engaging patient, carer and clinician groups directly.

BACKGROUND:There is increasing emphasis on reducing the use and improving the safety of mechanical restraint (MR) in psychiatric settings, and on improving the quality of evidence for outcomes. To date, however, a systematic appraisal of evidence has been lacking. METHODS:We included studies of adults (aged 18-65) admitted to inpatient psychiatric settings. We included primary randomised or observational studies from 1990 onwards that reported patterns of MR and/or outcomes associated with MR, and qualitative studies referring to an index admission or MR episode. We presented prevalence data only for studies from 2010 onwards. The risk of bias was assessed using an adapted checklist for randomised/observational studies and the Newcastle-Ottawa scale for interventional studies. RESULTS:We included 83 articles on 73 studies from 1990-2022, from 22 countries. Twenty-six studies, from 11 countries, 2010 onwards, presented data from on proportions of patients/admissions affected by MR. There was wide variation in prevalence (<1-51%). This appeared to be mostly due to variations in standard protocols between countries and regions, which dictated use compared to other restrictive practices such as seclusion. Indications for MR were typically broad (violence/aggression, danger to self or property). The most consistently associated factors were the early phase of admission, male sex, and younger age. Ward and staff factors were inconsistently examined. There was limited reporting of patient experience or positive effects. CONCLUSIONS:MR remains widely practiced in psychiatric settings internationally, with considerable variation in rates, but few high-quality studies of outcomes. There was a notable lack of studies investigating different types of restraint, indications, clinical factors associated with use, the impact of ethnicity and language, and evidence for outcomes. Studies examining these factors are crucial areas for future research. In limiting the use of MR, some ward-level interventions show promise, however, wider contextual factors are often overlooked.

BACKGROUND:Scalable assessment tools for precision psychiatry are of increasing clinical interest. One clinical risk assessment that might be improved by such approaches is assessment of violence perpetration risk. This is an important adverse outcome to reduce for some people presenting to services for first-episode psychosis. A prediction tool (Oxford Mental Illness and Violence (OxMIV)) has been externally validated in these services, but clinical acceptability and role need to be examined and developed. AIMS:This study aimed to understand clinical use of the OxMIV tool to support violence risk management in early intervention in psychosis services in terms of acceptability to clinicians, patients and carers, practical feasibility, perceived utility, impact and role. METHOD:A mixed methods approach integrated quantitative data on utility and patterns of use of the OxMIV tool over 12 months in two services with qualitative data from interviews of 20 clinicians and 12 patients and carers. RESULTS:The OxMIV tool was used 141 times, mostly in new assessments. Required information was available, with only family history items scored unknown to any notable degree. The OxMIV tool was deemed helpful by clinicians in most cases, especially if there were previous risk concerns. It was acceptable practically, and broadly for the service, for which its concordance with clinical judgement was important. Patients and carers thought it could improve openness. There was some limited impact on plans for clinical support. CONCLUSIONS:The OxMIV tool met an identified clinical need to support clinical assessment for violence risk. Linkage to intervention pathways is a research priority.

Patient and Public Involvement and Engagement (PPIE) is important in secure psychiatric research because it can help ensure that research is relevant and meaningful, and a positive experience for those participating. However, there are significant challenges to embedding PPIE in research in secure hospital settings, including practical barriers to involvement. A lack of reporting of PPIE practices makes it harder for researchers to learn from previous projects, leading to missed opportunities to improve PPIE in secure settings, and there are no current setting-specific guidelines for best practice. The CORAS study aims to examine collaborative risk assessment within secure psychiatric settings. In this study, PPIE is fully integrated throughout the research cycle, and this protocol describes the PPIE methodology being adopted. By highlighting these approaches and principles, this protocol is intended to be used as a transferrable framework for developing best practice for PPIE in research in these settings. This protocol describes the ways in which we will ensure that PPIE remains central to each stage of the research project, from the formation of a smaller grant application PPIE group, through to dissemination of outputs. We discuss principles of recruitment into the PPIE group, ensuring that all areas of the secure mental health pathway are represented, and formally embracing equality, diversity and inclusion principles through the use of an Equality Impact Assessment. We also describe the core activities of the PPIE group, including the co-design of the research materials, recruitment strategies and dissemination plans, how the impact of PPIE will be examined, and practical elements such as around reimbursement and ensuring the wellbeing of PPIE group members. PPIE in secure mental health service research is important and challenging. This protocol outlines how we will address these challenges and ensure that PPIE is fully embedded in the design and delivery of a large study in secure settings. Although the prospective nature of this protocol precludes the sharing of outcomes and learning from the PPIE, it can nevertheless serve as a transferrable framework for the development that is urgently required in this clinical research field, as well as allow transparent future reporting of what was achieved. Involving people with their own lived experience in the design and running of clinical research studies can improve the quality and impact of these studies, as well as the experience for people taking part in them. In some clinical settings this involvement might be more difficult. In secure psychiatric hospitals things like security can make it difficult for people to be involved in this way in research. There is not much guidance available for researchers on how to do this better when running studies in secure settings. The CORAS study (COllaborative Risk ASsessment and management in secure services) is a research study in these settings that is exploring how to involve patients and carers in their risk assessments and risk management plans (or safety plans). We have developed detailed plans for how to make sure that patients and carers have a central role in all areas of this study, including designing parts of the study and how best to make sure that the results of the study reach patients and carers. This paper outlines how we are planning to do this, so that other researchers designing studies in these clinical settings can understand and build on some of the practical ways of involving people with lived experience.

The use of clinical prediction models to produce individualized risk estimates can facilitate the implementation of precision psychiatry.As a source of data from large, clinically representative patient samples, electronic health records (EHRs) provide a platform to develop and validate clinical prediction models, as well as potentially implement them in routine clinical care.The current review describes promising use cases for the application of precision psychiatry to EHR data and considers their performance in terms of discrimination (ability to separate individuals with and without the outcome) and calibration (extent to which predicted risk estimates correspond to observed outcomes), as well as their potential clinical utility (weighing benefits and costs associated with the model compared to different approaches across different assumptions of the number needed to test).We review 4 externally validated clinical prediction models designed to predict psychosis onset, psychotic relapse, cardiometabolic morbidity, and suicide risk.We then discuss the prospects for clinically implementing these models and the potential added value of integrating data from evidence syntheses, standardized psychometric assessments, and biological data into EHRs.Clinical prediction models can utilize routinely collected EHR data in an innovative way, representing a unique opportunity to inform real-world clinical decision making.Combining data from other sources (e.g., meta-analyses) or enhancing EHR data with information from research studies (clinical and biomarker data) may enhance our abilities to improve the performance of clinical prediction models.

AIM:Clinical services for early psychosis seek to improve prognosis for a range of adverse outcomes. For some individuals, perpetration of violence is an important potential outcome to reduce. How these clinical services currently assess this risk however is uncertain. This study aimed to address this gap by using qualitative methods to examine in depth current approaches, attitudes and challenges to assessing violence risk in this clinical setting, from the perspectives of multidisciplinary clinicians, patients and carers. METHODS:Participants were recruited from two UK Early Intervention in Psychosis services. Semi-structured individual interviews were undertaken using a topic guide. In addition, clinical vignettes were presented to clinician participants as a probe to prompt discussion. Data were analysed using thematic analysis, informed by the constant comparative method. RESULTS:We conducted 30 qualitative interviews, of 18 clinicians and 12 patients and carers. Themes developed from clinician interviews included key difficulties of low confidence, limited training, accessing collateral information and variation in how risk is appraised and communicated. Potential stigma and sensitivity of the topic of violence were perceived as barriers to its discussion. Patient and carer perspectives provided insight into how to address barriers, and highlighted the importance of an open approach, including with families. CONCLUSIONS:We recommend developing contextually appropriate pathways to collaboratively assess violence risk and identify modifiable needs to reduce this risk, and for practical improvements in training and information-sharing.

Forensic mental health services provide crucial interventions for society. Such services provide care for people with mental disorders who commit violent and other serious crimes, and they have a key role in the protection of the public. To achieve these goals, these services are necessarily expensive, but they have been criticised for a high-cost, low-volume approach, for lacking consistent standards of care, and for neglecting human rights and other ethical considerations. A key concern is an insufficient evidence base to justify common practices, such as restricting leave from hospital and detaining patients for long periods. There is also insufficient quality evidence for core interventions, including psychological therapies, pharmacotherapy, and seclusion and restraint. The causes for this evidence deficit are complex but include insufficient investment in research infrastructure and fragmentation and isolationism of services, both nationally and internationally. In this Personal View, we highlight some of the major gaps in the forensic mental health evidence base and the challenges in addressing these gaps. We suggest solutions with implications at clinical, societal, and public health policy levels.

To address the societal harms of violence, many violence prevention interventions have been developed, tested, and implemented in the general population. These have been reported in systematic reviews and meta-analyses, which have typically focused on one type of intervention or outcome. We aimed to provide a comprehensive overview of the current evidence regarding the effectiveness of different psychosocial interventions in reducing all forms of violence toward others. We have conducted an umbrella review of previous meta-analyses using standard approaches and converted findings on effectiveness into odds ratios. We tested for the underlying quality of the meta-analytic evidence by examining heterogeneity, excess statistical significance, prediction intervals, and small study effects. We identified 16 meta-analyses, including nine investigating psychosocial interventions, and five legislative and policy changes. Most meta-analyses reported positive effects of tested interventions. The strongest effects were found for sports-based initiatives, and the weakest for general population programs aimed at early childhood, youth development, and reducing sexual assault perpetration by men. Legislative changes had varying effectiveness. We conclude that simple, scalable, and cost-efficient programs, such as sport-based initiatives, have the clearest empirical support as population-based approaches to violence prevention.

BACKGROUND:Although structured tools have been widely used to predict violence risk in specialist mental health settings, there is uncertainty about the extent and quality of evidence of their predictive performance. We aimed to systematically review the predictive performance of tools used to assess violence risk in forensic mental health, where they are routinely administered. METHODS:In our systematic review and meta-analysis, we followed PRISMA guidelines and searched four databases (PsycINFO, Embase, Medline, and Global Health) from database inception to Nov 1, 2022, to identify studies examining the predictive performance of risk assessment tools in people discharged from forensic (secure) mental health hospitals. Systematic and narrative reviews were excluded from the review. Performance measures and descriptive statistics were extracted from published reports. A quality assessment was performed for each study using the Prediction Model Risk of Bias Assessment Tool. Meta-analysis was conducted on the performance of instruments that were independently externally validated with a sample size greater than 100. The study was registered with PROSPERO, CRD42022304716. FINDINGS:We conducted a systematic review of 50 eligible publications, assessing the predictive performance of 36 tools, providing data for 10 460 participants (88% men, 12% women; median age [from 47 studies] was 35 years, IQR 33-38) from 12 different countries. Post-discharge interpersonal violence and crime was most often measured by new criminal offences or recidivism (47 [94%] of 50 studies); only three studies used informant or self-report data on physical aggression or violent behaviour. Overall, the predictive performance of risk assessment tools was mixed. Most studies reported one discrimination metric, the area under the receiver operating characteristic curve (AUC); other key performance measures such as calibration, sensitivity, and specificity were not presented. Most studies had a high risk of bias (49 [98%] of 50), partly due to poor analytical approaches. A meta-analysis was conducted for violent recidivism on 29 independent external validations from 19 studies with at least 100 patients. Pooled AUCs for predicting violent outcomes ranged from 0·72 (0·65-0·79; I2=0%) for H10, to 0·69 for the Historical Clinical Risk Management-20 version 2 (95% CI 0·65-0·72; I2=0%) and Violence Risk Appraisal Guide (0·63-0·75; I2=0%), to 0·64 for the Static-99 (0·53-0·73; I2=45%). INTERPRETATION:Current violence risk assessment tools in forensic mental health have mixed evidence of predictive performance. Forensic mental health services should review their use of current risk assessment tools and consider implementing those with higher-quality evidence in support. FUNDING:Wellcome Trust.

BACKGROUND:Violence perpetration is a key outcome to prevent for an important subgroup of individuals presenting to mental health services, including early intervention in psychosis (EIP) services. Needs and risks are typically assessed without structured methods, which could facilitate consistency and accuracy. Prediction tools, such as OxMIV (Oxford Mental Illness and Violence tool), could provide a structured risk stratification approach, but require external validation in clinical settings. OBJECTIVES:We aimed to validate and update OxMIV in first-episode psychosis and consider its benefit as a complement to clinical assessment. METHODS:A retrospective cohort of individuals assessed in two UK EIP services was included. Electronic health records were used to extract predictors and risk judgements made by assessing clinicians. Outcome data involved police and healthcare records for violence perpetration in the 12 months post-assessment. FINDINGS:Of 1145 individuals presenting to EIP services, 131 (11%) perpetrated violence during the 12 month follow-up. OxMIV showed good discrimination (area under the curve 0.75, 95% CI 0.71 to 0.80). Calibration-in-the-large was also good after updating the model constant. Using a 10% cut-off, sensitivity was 71% (95% CI 63% to 80%), specificity 66% (63% to 69%), positive predictive value 22% (19% to 24%) and negative predictive value 95% (93% to 96%). In contrast, clinical judgement sensitivity was 40% and specificity 89%. Decision curve analysis showed net benefit of OxMIV over comparison approaches. CONCLUSIONS:OxMIV performed well in this real-world validation, with improved sensitivity compared with unstructured assessments. CLINICAL IMPLICATIONS:Structured tools to assess violence risk, such as OxMIV, have potential in first-episode psychosis to support a stratified approach to allocating non-harmful interventions to individuals who may benefit from the largest absolute risk reduction.

Antipsychotic medications are widely prescribed in psychotic illnesses and other mental disorders. Effectiveness is well-established, particularly for reducing symptoms such as delusions and hallucinations, but can be impacted by tolerability. Adverse effects are wide-ranging, and vary between antipsychotics, which is clinically important. This umbrella review aimed to comprehensively summarise the extent and quality of evidence for adverse effects associated with antipsychotic use in people with mental disorders. We included 32 meta-analyses of randomised trials and observational studies. The overall robustness of reported associations was considered in terms of review quality, heterogeneity, excess significance bias, and prediction intervals. Using this approach, endocrine and metabolic, movement-related, and sedation and sleep problems were the clinical domains with strongest evidence. The overall quality of included meta-analyses was low, and individual adverse effects were not typically examined in meta-analyses of both randomised trials and observational study designs. Future reviews should focus on adhering to methodological guidelines, consider the complementary strengths of different study designs, and integrate clinically relevant information on absolute rates and severity of adverse effects.

To address societal harms of violence, many violence prevention interventions have been developed, tested, and implemented in the general population. These have been reported in systematic reviews and meta-analyses, which have typically focused on one type of intervention or outcome. We have conducted an umbrella review of previous meta-analyses using standard approaches, and converted findings on effectiveness into odds ratios. We tested for the underlying quality of the meta-analytic evidence by examining heterogeneity, statistical excess, prediction intervals, and small study effects. We identified 16 meta-analyses, including 9 investigating psychosocial interventions, and 5 legislative and policy changes. Most meta-analyses reported positive effects of tested interventions. The strongest effects were found for sports-based initiatives, and the weakest for general population programmes aimed at early childhood, youth development, and reducing sexual assault perpetration by men. Legislative changes had varying effectiveness. We conclude that simple, scalable, and cost-efficient programmes, such as sport-based initiatives, have the clearest empirical support as population-based approaches to violent prevention.

This article considers the current stance of forensic inpatient units in the UK on sex and relationships. In the absence of national guidance, units typically adopt policies that are universally restrictive rather than based on individual risk assessments. The grounds for this in terms of protecting the physical and mental health of inpatients are considered, alongside the potential unintended consequences. It is understood that relationships occur despite these policies. The paths to legality of universal restrictions to sex and relationships as human rights are also discussed. It is concluded that consideration should be given to bringing sex and relationships more in line with other aspects of risk and restriction. By adopting a more individually tailored approach, particularly in lower security settings and where individuals are moving towards community reintegration, safety, and wellbeing may potentially be improved rather than compromised. To implement any shift away from total prohibition, clinicians in these settings would require a clear guiding framework.

Early Intervention in psychosis (EIP) teams are the gold standard treatment for first-episode psychosis (FEP). EIP is time-limited and clinicians are required to make difficult aftercare decisions that require weighing up individuals’ wishes for treatment, risk of relapse, and health service capacity. Reliable decision-making tools could assist with appropriate resource allocation and better care. We aimed to develop and externally validate a readmission risk tool for application at the point of EIP discharge. All persons from EIP caseloads in two NHS Trusts were eligible for the study. We excluded those who moved out of the area or were only seen for assessment. We developed a model to predict the risk of hospital admission within a year of ending EIP treatment in one Trust and externally validated it in another. There were n = 831 participants in the development dataset and n = 1393 in the external validation dataset, with 79 (9.5%) and 162 (11.6%) admissions to inpatient hospital, respectively. Discrimination was AUC = 0.76 (95% CI 0.75; 0.77) in the development dataset and AUC = 0.70 (95% CI 0.66; 0.75) in the external dataset. Calibration plots in external validation suggested an underestimation of risk in the lower predicted probabilities and slight overestimation at predicted probabilities in the 0.1–0.2 range (calibration slope = 0.86, 95% CI 0.68; 1.05). Recalibration improved performance at lower predicted probabilities but underestimated risk at the highest range of predicted probabilities (calibration slope = 1.00, 95% CI 0.79; 1.21). We showed that a tool for predicting admission risk using routine data has good performance and could assist clinical decision-making. Refinement of the model, testing its implementation and further external validation are needed.

In this Review, we summarise evidence on the association between different mental disorders and violence, with emphasis on high quality designs and replicated findings. Relative risks are typically increased for all violent outcomes in most diagnosed psychiatric disorders compared with people without psychiatric disorders, with increased odds in the range of 2-4 after adjustment for familial and other sources of confounding. Absolute rates of violent crime over 5-10 years are typically below 5% in people with mental illness (excluding personality disorders, schizophrenia, and substance misuse), which increases to 6-10% in personality disorders and schizophrenia spectrum disorders, and to more than 10% in substance misuse. Past criminality and comorbid substance misuse are strongly predictive of future violence in many individual disorders. We reviewed national clinical practice guidelines, which vary in content and require updating to reflect the present epidemiological evidence. Standardised and clinically feasible approaches to the assessment and management of violence risk in general psychiatric settings need to be developed.