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.

Labels in healthcare influence perceptions, treatment and stigma. Although they can aid diagnosis and guide care, pejorative labels can dehumanise and perpetuate prejudice. Person-first language, which foregrounds the individual rather than a condition or behaviour, has been linked to reduced blame, stigma and social distance across mental health and forensic populations. Evidence suggests it may foster empathy, recovery-oriented attitudes and rehabilitation, while challenging essentialist and pessimistic views of mental illness and offending. Limitations include minimising structural coercion and lived experience. This editorial explores the evidence, mechanisms and practical applications of person-first language in forensic mental health, advocating cautious implementation and further research.

Electronic monitoring ('tracking') of individuals has been used in the UK criminal justice system for over three decades, and its use is increasing. Electronic monitoring has more recently been implemented in forensic psychiatric services, which has generated considerable debate about the appropriateness of its use in clinical settings, and about legal and ethical concerns. The purpose of this article is to formally address the ethical issues that arise from using electronic monitoring in forensic psychiatry. These issues are considered using the Four Principles approach to medical ethics, namely autonomy, beneficence, non-maleficence, and justice. We conclude that by adopting a patient-centred approach, where informed consent is sought, and the patient's best interests remain central to the decision-making process, electronic monitoring is both ethical and justifiable. More robust studies are required to develop standardised clinical guidelines for the use of EM in forensic psychiatry, and to apply the theory of patient-centred, consent-driven care to practice.

Increasing evidence from neuroimaging and neurophysiological studies points to structural, functional, and connectivity abnormalities in youths and adults meeting criteria for conduct disorder with and without callous-unemotional traits (CD+/-CU), and antisocial personality disorder with and without psychopathy (ASPD+/-P), respectively. These findings point to neural underpinnings for the core traits and behaviours of these conditions, including aggression and violence, callousness/lack of affective empathy, and maladaptive decision-making. Until recently however, the role of neurochemical systems has been relatively under-researched, with little evidence from well-characterised clinical samples. Over the past decade, new insights have begun to emerge, through more targeted investigations in samples of antisocial populations, particularly in relation to the role of oxytocin, and that of glutamate and GABA in maintaining brain excitatory-inhibitory balance. Alongside this, advances in technology have opened new avenues for probing these mechanisms more precisely. In this paper, we provide an overview of existing evidence, with a focus on recent progress and methodologically robust studies in clinical samples of antisocial populations. We pay particular attention to aggression and violence, given the primacy of these behaviours in CD+/-CU and ASPD+/-P. Within each domain, we propose specific strategies for future research, including novel methodological approaches. We conclude with a suggested set of priorities to help move this field forward towards network and systems understanding of these disorders, and therapeutic interventions.

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.

Behavioural, structural, and functional neuroimaging differences exist between individuals with antisocial personality disorder with (ASPD + P) or without psychopathy (ASPD-P). However, the aetiological mechanisms underpinning such differences remain unclear, hindering treatment development. Intranasal oxytocin (OT) has shown modulatory effects on social brain function in healthy and antisocial populations. We investigated the effects of OT on resting-state brain function in individuals with violent offending histories with ASPD+/-P using arterial spin labelling to measure regional cerebral blood flow (rCBF). A double-blind, placebo-controlled, crossover design was employed with males with ASPD (ASPD + P: N = 17, ASPD-P: N = 14) and healthy male non-offenders (N = 22). Both ASPD subtypes exhibited reduced rCBF in frontotemporal regions compared to non-offenders. Individuals with ASPD + P showed significantly greater rCBF increases in posterior default mode network regions compared to individuals with ASPD-P. OT administration selectively decreased rCBF in the left basal ganglia of the ASPD-P group, an effect not observed in ASPD + P or non-offender groups. These findings highlight functional brain differences between individuals with ASPD + P and ASPD-P at rest and demonstrate oxytocin’s differential impact on resting-state measures. Further understanding of the origins of these neurobiological differences could inform targeted therapeutic strategies for individuals with ASPD with and without psychopathy.

Background Co-operation is a core component of human social interaction. Conflict emerges when another’s unfairness is perceived and retaliation in the form of non-cooperative behaviour or retaliatory punishment may emerge. This may be particularly relevant in men with antisocial personality disorder and psychopathy, who demonstrate impulsive behaviour and low thresholds for discharge of aggression. Methods In a sample of violent male offenders with ASPD (n= 22) with (+P, n =12) and without (-P, n= 10) psychopathy, we used a paradigm of social provocation (the Social Fairness game) in conjunction with fMRI to measure behavioural and neural response to social provocation and compared this to healthy non-offenders (n=20), and investigated the effects of intranasal oxytocin (40 I.U.), which is known to modulate social behaviours, on social provocation across groups. Results Counter to predictions, those with ASPD+/-P did not significantly differ from healthy non-offenders at the behavioural or neural level. Conclusions We discuss the potential explanations for these findings and our conclusion that this experiment has failed to provide a satisfactory model of social provocation in ASPD+/-P with which to test decisions to co-operate or retaliate, or oxytocin’s effects thereon.

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.

One of the most highly replicated neural correlates of Conduct Problems (CP) is amygdala hypoactivity to another person’s fear. We recently reported that this correlate was only observed in boys with persistent CP (i.e. antisocial behaviour that persisted following a gold-standard psychological intervention), suggesting that amygdala hypoactivity to fear could be an important neural signature for treatment-resistant CP, and a putative target for future treatments. Potential treatment candidates include the oxytocin system, as this has been reported to modulate amygdala activity and social behaviour across species. Further, in adults with antisocial personality disorder, intranasal oxytocin improved facial emotion recognition for fearful and happy faces. However, to-date, no-one has studied whether intranasal oxytocin can normalise neural processing differences in children with CP. Twenty boys (mean age 9.85±1.26 years) with persistent CP underwent functional magnetic resonance imaging in a within-subject randomised control design to investigate whether, compared to placebo, a single-dose of intranasal oxytocin could ‘shift’ abnormal neural processing to fear. Oxytocin failed to reduce amygdala hypoactivity to fearful faces, but increased activation in the posterior cingulate cortex / precuneus to happy faces. These findings tentatively suggest that intranasal oxytocin may promote a more neurotypical profile in treatment-resistant CP children, therefore, supporting the merit of investigating oxytocin in further larger clinical studies in this population.

Sex offenders and non-sexual violent offenders display distinct cognitive distortions that shape their offenses. Some evidence suggests that early maladaptive schemas which reflect individuals’ fundamental cognitions and beliefs, contribute to these cognitive distortions. However, these have not been systematically appraised. We conducted a systematic review to synthesize the evidence regarding the schema profiles of sex offenders and non-sexual violent offenders, and to explore differences in schemas between these offender types. Eight studies met the inclusion criteria. Within the sex offender category, rapists and child sex offenders endorsed similar schemas. For non-sexual violent offenders, schemas related to self-control issues and self-entitlement were most prominent. Sex offenders demonstrated more schemas that endorsed negative perceptions of themselves and others than violent offenders. Findings also suggest that atypical sexual interests and mental disorders may be important. This evidence highlights the need for a more fine-tuned understanding of the cognitive profiles of sexual and non-sexual violent offenders and for developing schema-based offender management and rehabilitation services.

Men with antisocial personality disorder (ASPD) with or without psychopathy (+/−P) are responsible for most violent crime in society. Development of effective treatments is hindered by poor understanding of the neurochemical underpinnings of the condition. Men with ASPD with and without psychopathy demonstrate impulsive decision-making, associated with striatal abnormalities in functional neuroimaging studies. However, to date, no study has directly examined the potential neurochemical underpinnings of such abnormalities. We therefore investigated striatal glutamate: GABA ratio using Magnetic Resonance Spectroscopy in 30 violent offenders (16 ASPD-P, 14 ASPD + P) and 21 healthy non-offenders. Men with ASPD +/− P had a significant reduction in striatal glutamate : GABA ratio compared to non-offenders. We report, for the first time, striatal Glutamate/GABA dysregulation in ASPD +/− P, and discuss how this may be related to core behavioral abnormalities in the disorders.

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.

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Adults with antisocial personality disorder with (ASPD + P) and without (ASPD – P) psychopathy commit the majority of violent crimes. Empathic processing abnormalities are particularly prominent in psychopathy, but effective pharmacological interventions have yet to be identified. Oxytocin modulates neural responses to fearful expressions in healthy populations. The current study investigates its effects in violent antisocial men. In a placebo-controlled, randomized crossover design, 34 violent offenders (19 ASPD + P; 15 ASPD – P) and 24 healthy non-offenders received 40 IU intranasal oxytocin or placebo and then completed an fMRI morphed faces task examining the implicit processing of fearful facial expressions. Increasing intensity of fearful facial expressions failed to appropriately modulate activity in the bilateral mid-cingulate cortex in violent offenders with ASPD + P, compared with those with ASPD – P. Oxytocin abolished these group differences. This represents evidence of neurochemical modulation of the empathic processing of others’ distress in psychopathy.

Individuals with disruptive behaviour disorders in youth and antisocial personality disorder and psychopathy as adults share some clinical characteristics, but also diverge in important ways. Existing meta-analyses of structural imaging studies suggest abnormalities within these disorders; however, so far none has examined the role of variability. Here we performed a systematic review and meta-analysis to examine both variability (coefficient of variation ratio) and magnitude of brain volume differences between antisocial groups and healthy controls (quantified using Hedges’ g). A comprehensive search was conducted of PubMed, EMBASE, Web of Science, Scopus and PsycINFO from inception to 31 January 2022 (pre-registered with PROSPERO, ID number CRD42021250980 , registered 25 June 2021). We included studies which included individuals with disruptive behaviour disorder (± callous–unemotional traits) or antisocial personality disorder (± psychopathy), defined using standardized classificatory tools (Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases criteria for disruptive behaviour disorders and antisocial personality disorder, Psychopathy Checklist: Revised or Psychopathy Checklist: Screening Version for psychopathy) and a healthy control group, and which had sufficient data to extract mean and standard deviations, or t or P values, for both groups. We measured the relative variability of brain regions in antisocial individuals compared with controls, by using the log coefficient of variability ratio. Between-group differences in mean volumes were quantified using standardized mean difference. Risk of bias was assessed using modified version of the Newcastle–Ottawa Scale for case–control studies. Twenty-three studies met inclusion criteria. In antisocial individuals, there was significantly increased variability for total grey matter (Z = −2.6581, P = 0.0079) and overall decreases in mean volume for total whole brain (g = −0.41; 95% confidence interval (CI) −0.67 to −0.15, P = 0.0016), total grey matter (g = −0.6; 95% CI −0.93 to −0.26, P = 0.004) and amygdala (g = −0.89; 95% CI −1.55 to −0.22, P = 0.009), compared with healthy controls. This suggests a key role for structural variability in clinical divergence within these disorders. The key limitations were lack of studies for some brain regions of interest, including insula, and inconsistent clinical phenotyping. Further studies should seek to specify how this neurobiological variability maps to clinical variability and whether this holds potential value as a biomarker to guide prognosis or treatment selection. Tully et al. detected increased variability in brain total grey matter volume in individuals with disruptive behaviour disorder and antisocial personality disorder.

BACKGROUND Transfer to a psychiatric hospital of prisoners who need inpatient treatment for a mental disorder is an important part of prison healthcare in the UK. It is an essential factor in ensuring the principle of equivalence in the treatment of prisoners. In England and Wales, delays in transferring unwell prisoners to hospital were identified by the 2009 Bradley Report. There has been no subsequent systematic review of progress in so doing nor a corresponding appraisal of transfer arrangements in other parts of the world. AIM To conduct a systematic review of international literature about transfers of mentally unwell individuals from prison to hospital for the treatment of mental disorder since 2009. METHOD Eight databases were searched for data-based publications using terms for prison and transfer to hospital from 1 January 2009 to 4 August 2022. Inclusion criteria limited transfer to arrangements for pre-trial and sentenced prisoners going to a health service hospital, excluding hospital orders made on the conclusion of criminal hearing. RESULTS In England, four articles were identified, all showing that transfer times remain considerably longer than the national targets of 14 days (range, 14 days to >9 months); one study from Scotland found shorter mean transfer times, but more patients had been transferred to psychiatric intensive care units than to secure forensic hospitals. There were only two studies that investigated prison to hospital transfers for mental disorder from outside the UK and only one reported time-to-transfer data. CONCLUSIONS Findings from this literature review highlight failures to resolve transfer delays in England and provide little evidence about the problem elsewhere. Given the lack of data, it is unclear whether other countries do not have this problem or simply that there has been no research interest in it. A possible confounding factor here is that, in some countries, all treatment for prisoners' mental disorders occurs in prison. However, the principle that prisons are not hospitals seems important when people need inpatient care. Prospective, longitudinal cohort studies are urgently needed to map transfer times and outcomes.

Electronic monitoring (EM) of individuals has been used by the criminal justice system for the past thirty years, and in the UK, use is on the increase. Its use has been justified as an alternative to prison to reduce recidivism and allowing early release of prisoners, however, the evidence base for this remains mixed. In 2010, it was employed for the first time in a forensic psychiatry setting. A study investigating the effects of EM on leave episodes concluded that EM may improve the speed of patient progress and reduce the length of admission, leading to reduced costs and increased public safety. However, the intervention generated considerable controversy and sparked discussion about ethical concerns. Here, we consider specifically legal and human rights issues that emerge from use of EM in forensic healthcare settings, scrutinising its use in the context of the Mental Health Act and the Human Rights Act. We conclude that EM is legal and justifiable, providing it is used judiciously and with due consideration of concerns for the individual and the given context.

Psychopathy is a severe form of personality disturbance, resulting in a detrimental impact on individuals, healthcare systems, and society as a whole. Until relatively recently, most research in psychopathy has focused on male samples, not least because of its link with criminal behavior and the large proportion of violent crime committed by men. However, psychopathy in women also leads to considerable problems at an individual and societal level, including substance misuse, poor treatment outcomes, and contribution to ever-increasing numbers of female prisoners. Despite this, due to relative neglect, most research into adult female psychopathy is underpowered and outdated. We argue that the field needs revitalizing, with a focus on the developmental nature of the condition and neurocognitive research. Recent work international consortia into conduct disorder in female youth-a precursor of psychopathy in female adults-gives cause for optimism. Here, we outline key strategies for enriching research in this important field with contemporary approaches to other psychiatric conditions.

BACKGROUND:Knowledge and attitudes of professionals both pose a potential barrier to diagnosis and treatment of mental disorders. However, knowledge and attitudes about conduct disorder in professionals working with young people are poorly understood. Little is known about the impact of occupation, direct and indirect (training and education) experience, or the interrelationship between knowledge and attitudes.METHODS:We conducted an online survey of 58 participants, including Psychology Staff, Teaching Staff, Care Staff, and Other Non-Clinical Staff. A questionnaire comprising three subscales (causes, treatments, and characteristics) measured knowledge. A thermometer scale measured global attitudes. Open-ended response measures were used to measure four attitude components: stereotypic beliefs (about characteristics), symbolic beliefs (about the holder's traditions), affect, and past behaviour. Primary analysis explored the impact of occupation, direct experience, and indirect experience on outcome measures. A secondary exploratory analysis was conducted to explore the relationship between knowledge and attitudes.RESULTS:Psychology Staff had significantly more favourable global attitudes (F = 0.49, p = 0.01) and symbolic beliefs (F = 0.57, p = 0.02) towards those with conduct disorder than Teaching Staff; there were no other significant group differences in attitudes. Psychology staff had more knowledge about conduct disorder than other groups, though the differences were not significant. Direct and indirect experience were associated with greater knowledge (direct: d = 0.97, p = 0.002; indirect d = 0.86, p = 0.004) and favourable global attitudes (direct: d = 1.12, p < 0.001; indirect: d = 0.68, p = 0.02). Secondary exploratory analyses revealed significant positive correlations between: all knowledge variables with global attitudes; total knowledge with past behaviour; and affect and knowledge of causes with past behaviour.CONCLUSIONS:Psychology-based staff may have more favourable attitudes towards children with conduct disorder than teachers, primarily due to direct and indirect experience with the disorder. Our sample may have been too small to detect overall or within-group effects of knowledge or attitudes, however exploratory analyses showing a positive correlation between knowledge and attitudes suggest education may be critical in supporting teachers and other groups in their approaches to this challenging group of young people.