A survey was conducted to determine attitudes, knowledge, and educational needs of mental health professionals regarding pharmacogenomics. We recruited 128 clinicians working in mental health in England, and we assessed their experiences using an adapted version of the "U-PGx Clinician's Questionnaire". Responding clinicians had positive attitudes towards pharmacogenomics testing, although they lacked confidence in ordering and interpreting tests, for which most had never received any formal training. Only 6% of clinicians answered all 4 knowledge testing questions correctly, and barriers to clinical implementation included lack of familiarity and knowledge for several pharmacogenomics concepts, such as drug metabolism and genetics, as well as needing support from their working institution. Looking ahead, we found that accredited workshops and patient cases were preferred learning formats, and we suggest tailored education programmes to enable mental health professionals to apply pharmacogenomics in clinical practice.

BackgroundForensic mental health care has evolved from mixed-sex provision to specialised sex-specific services. It is important to understand how the characteristics of women admitted to medium secure care have changed over time and how this may impact on their outcomes after discharge.ObjectiveThe study aims to describe and compare admission and discharge characteristics of two consecutive cohorts; women admitted between 1983 and 2001 to a mixed-sex medium secure care (‘Mixed’ cohort) and women admitted between 2005 and 2013 to single-sex medium secure care (‘Specialised’ cohort).MethodsData came from a 30-year study of outcomes for first admissions to an NHS medium secure hospital (the ALACRITy study). Follow-up data were available up to a census date of June 30th 2013.Results93 women comprised the Mixed cohort (mean age 29.3 years; 81% White ethnicity; 49% personality disorder diagnosis) and 45 women comprised the Specialised cohort (mean age 32.4 years; 76% White ethnicity; 49% personality disorder diagnosis). The Specialised cohort were more likely than the Mixed cohort to be admitted from high security, or under a forensic section of the Mental Health Act. The Specialised cohort were more likely than the Mixed cohort to have previous convictions, or to have committed a ‘grave’ index offence warranting a life sentence. Over 95% of all women had received previous inpatient psychiatric care. The Specialised cohort had greater prevalence of alcohol use, self-harm and childhood adversity than the Mixed cohort. At the census, 99% of the Mixed cohort and 42% of the Specialised cohort had been discharged. Women in the Specialised cohort had a longer median length of stay than the Mixed cohort; 859 days and 229 days respectively. Over 80% of patients in the Mixed cohort were readmitted during the follow-up period.ConclusionThe study provides empirical data for two consecutive cohorts of women admitted to one medium secure hospital over the course of thirty years. Women admitted to single-sex services had more criminological and adverse trauma histories than women admitted to the earlier mixed-sex service. Further research is required to establish the long-term outcomes of women admitted to specialised single-sex medium secure care.

Purpose The benefits of physical activity for people with severe mental illness (SMI) is widely recognised but for those in medium secure settings there are additional environmental barriers to being active that have not been fully explored. The aim of this study was to explore the perceived barriers and facilitators from the perspective of staff within the medium secure setting. Method Semi-structured focus groups were conducted with qualified and unqualified staff (n=24) across two UK medium secure NHS settings. Michie’s COM-B framework was used to inform the topic guide and the analysis of the data. Results The opportunities to be active in medium secure settings depend not only on access to facilities but also staff availability and willingness to support such activities. When an individualised approach is taken, and staff are skilled and motivated to support such activities then it is possible for people with SMI in medium secure settings to be physically active. Conclusion People with SMI in secure settings have reduced autonomy to increase their own physical activities but it was suggested that with the appropriate opportunities and the motivation of staff their capability to be active could be enhanced.

BackgroundIn the UK, there are approximately 3500 individuals detained in medium secure service. Service users in such settings have complex and severe mental illness (SMI), often with co-morbid physical health problems, shorter life expectancy and low levels of physical activity (PA). However, there are few studies about PA interventions for medium secure service users in the United Kingdom. Therefore, the aim of the study was to co-produce, with medium secure service users and staff, the content and delivery of an intervention to increase PA.MethodsA feasibility and acceptability study were conducted to test the PA intervention using the Capability, Opportunity, Motivation Behaviour Change Model (COM-B model) as the underpinning theoretical model. Both female and male service users, with personality disorder and/or mental illness, were recruited from two medium secure services in the UK.Outcome measures were collected at baseline, after the intervention and at follow up (3-months after intervention), and included PA levels, mental well-being, data on recruitment and retention and causes of drop out.ResultsA total of 33 participants were recruited. Seven participants withdrew during the intervention period and 26 participants completed the PA intervention. During the follow up stage, three participants withdrew. Following the intervention participants increased PA and improved physical health and wellbeing. Overall, there was good retention for the PA interventionConclusionRetention rates and completeness of data at both study sites indicate that it is feasible and acceptable to co-produce, deliver and maintain commitment to a PA intervention in such settings for service users with SMI. A future pilot randomised controlled trial (RCT) will allow further understanding about the effectiveness of the PA intervention in medium secure psychiatric services.Clinical trial registrationhttps://doi.org/10.1186/ISRCTN15546527, ISRCTN Registry – ISRCTN15546527.

Abstract Purpose As part of a four-phase project, ‘Increasing Physical Activity in a Medium Service: The Development and Feasibility of a Physical ACTivity Intervention (IMPACT)’, the barriers and facilitators to increasing physical activity (PA) in medium secure psychiatric services, in the UK, were explored. Previous reviews have called for additional exploration into barriers and facilitators, as evidence has suggested a positive association between PA and the improvement in physical and psychological health for people with serious mental illnesses (SMI) and low activity levels. Methods A mixed-method approach was adopted. Questionnaires, co-developed with service users, were completed across two NHS study sites in England, UK (n = 68), collecting qualitative and quantitative data from service users in medium secure services. Two focus groups were also conducted to collect qualitative data (n = 24) from hospital staff and key stakeholders. Framework Analysis and the COM-B Model of Behaviour Change (C for Capability, O for Opportunity, M for Motivation and B for Behaviour) were used to analyse the data. For this paper, the qualitative data from both the questionnaires and the focus groups will be discussed. Results Similar themes were identified by the service users, hospital staff and key stakeholders. One main barrier discussed was environmental factors in secure services such as sedentary ward environments and the lack of autonomy in secure services. Main facilitators discussed were increasing the knowledge of benefits to PA and having structural guidance for personal development. Conclusion The barriers and facilitators identified will inform the remaining phases of the IMPACT project, including a co-produced PA intervention, based on overcoming the barriers and supporting the facilitators identified. A feasibility study will then test the PA Intervention. This feature of co-producing a PA intervention in medium secure services, based on barriers and facilitators, adds to the limited literature in this area. The aim of the IMPACT project is to inform future a pilot study and policies. Support/Source National Institute for Health and Care Research (NIHR) - Research for Patient Benefit Programme (IRAS ID 297420).

Aims People who have a serious mental illness have a higher prevalence of physical health problems as compared to the general population; with a 2–3 times greater risk of cardiovascular morbidity and mortality, double the risk of obesity and diabetes, three times the risk of hypertension and metabolic syndrome and five times the risk of dyslipidaemia than the general population. There is a concern that some antipsychotic drugs have metabolic consequences that contribute to the risk. As such, it is imperative that patients treated with antipsychotics receive appropriate health monitoring. Physical health monitoring of antipsychotic medications is an essential aspect of our practice, and despite assurance in previous audits, we agreed to monitor biannually to ensure we were maintaining standards. Additionally, this audit aimed to look more closely at special monitoring requirements for drugs such as Olanzapine, Chlorpromazine, Clozapine and Quetiapine which had not been measured in previous audits and would likely highlight some areas for improvement. Methods Audit standards were drawn from the Maudsley Prescribing Guidelines in Psychiatry 14th edition, in addition to NICE Guidance CG178 - Psychosis and schizophrenia in adults: prevention and management. A random number generator was used to select patients from each of the 7 wards, giving a sample size of 21 patients. Data were collected on Weight, BP, ECG and various blood tests conducted from February 2021 – February 2022. Data was collected from a combination of patient electronic record, CPA reports, and online blood results system. Data were inputted to MS Excel which created percentage compliance in each domain. Results 1. Blood Pressure: General compliance in the taking of BP met our standard of 100% 2. Weight: Annual monitoring compliance was 93% however compliance fell short for special recommendations for Clozapine, Olanzapine and Chlorpromazine. 3. ECG: Our compliance fell short in the recording of an ECG on admission, or at reaching target medication dose. Annual monitoring compliance was 93%. 4. Bloods: Annual compliance for FBC, LFT, U&Es, Lipids, Prolactin and 5. Glucose were 100%, however our compliance fell short for baseline recording and interim 3-6 monthly monitoring for various blood tests. Conclusion Overall results demonstrate good, safe practice, particularly during a challenging period for clinical teams. Shortfalls particularly at baseline were related to risk issues making investigations impractical. It was agreed that there should be an increased frequency of regular glucose monitoring and that HbA1c monitoring was a reasonable measure for this.

Background: Data from case series suggest that clozapine may benefit inpatients with borderline personality disorder (BPD), but randomised trials have not been conducted. Methods: Multicentre, double-blind, placebo-controlled trial. We aimed to recruit 222 inpatients with severe BPD aged 18 or over, who had failed to respond to other antipsychotic medications. We randomly allocated participants on a 1:1 ratio to receive up to 400 mg of clozapine per day or an inert placebo using a remote web-based randomisation service. The primary outcome was total score on the Zanarini Rating scale for Borderline Personality Disorder (ZAN-BPD) at 6 months. Secondary outcomes included self-harm, aggression, resource use and costs, side effects and adverse events. We used a modified intention to treat analysis (mITT) restricted to those who took one or more dose of trial medication, using a general linear model fitted at 6 months adjusted for baseline score, allocation group and site. Results: The study closed early due to poor recruitment and the impact of the COVID-19 pandemic. Of 29 study participants, 24 (83%) were followed up at 6 months, of whom 21 (72%) were included in the mITT analysis. At 6 months, 11 (73%) participants assigned to clozapine and 6 (43%) of those assigned to placebo were still taking trial medication. Adjusted difference in mean total ZAN-BPD score at 6 months was -3.86 (95% Confidence Intervals = -10.04 to 2.32). There were 14 serious adverse events; 6 in the clozapine arm and 8 in the placebo arm of the trial. There was little difference in the cost of care between groups. Interpretation: We recruited insufficient participants to test the primary hypothesis. The study findings highlight problems in conducting placebo-controlled trials of clozapine and in using clozapine for people with BPD, outside specialist inpatient mental health units. Trial registration ISRCTN18352058. https://doi.org/10.1186/ISRCTN18352058

Aims Compared with the general population, people with mental health disorders are at increased risk of negative physical and mental health outcomes following SARS-CoV-2 infection. In the UK, all adult mental health in-patients were offered COVID-19 vaccination as a priority group. Patients admitted to medium secure care have greatly increased mortality compared with the general population. Understanding COVID-19 vaccine uptake, and reasons for refusal, in patients in medium secure hospitals is important given the high prevalence of chronic physical health comorbidities such as obesity and diabetes, as these conditions are also associated with poor clinical outcomes in COVID-19 disease. Aims: To assess the proportions of patients who accepted or declined the COVID-19 vaccine, and explore their reasoning. To examine vaccine uptake between White and Black Asian minority ethnic (BAME) patients, and between younger/older patients. Methods The study took place at a medium secure hospital with male and female inpatients. All patients were offered a COVID-19 vaccine, and had a capacity and physical health evaluation completed by their Consultant Forensic Psychiatrist. Results Data regarding capacity to consent to the vaccine, acceptance/refusal, and demographics were retrospectively collected from the clinical records. In total, 85 patients (92.4% of eligible patients) had capacity to decide if they wanted the COVID-19 vaccine. Of these 68 (80.0%) consented and 17 (20.0%) declined to consent. A similar proportion of patients aged under and over 40 years old consented. Those from a BAME background were more likely to decline than White British patients. The reasons for capacitous refusal appeared similar to the general population. Conclusion COVID immunisation was broadly acceptable for patients in medium secure hospitals. The prevalence and reasoning of capacitous refusal appears similar to the general English population. The indication that BAME patients were more likely than White patients to decline the vaccination echoes the findings of research conducted in the Leicester general hospital. Further consideration needs to be given to how the uptake of COVID-19 vaccination can be improved in people with BAME ethnicity, especially as this group is also overrepresented in secure hospital settings. The study demonstrates that similar services should be able to approach the vaccination process with confidence. As many people with severe mental disorder also have high physical comorbidity that would increase the risk of a poor clinical outcome if they contracted COVID-19, protecting this vulnerable population through vaccination must be a priority for mental health services.

Summary Patients in medium secure hospitals may be at particularly increased risk of coronavirus disease 2019 (COVID-19) infection and complications. We undertook a service evaluation involving all current in-patients within a single, English medium secure hospital to describe the uptake of the COVID-19 vaccine among this population. Data regarding capacity to consent to the vaccine, acceptance/refusal of this (and reasons for refusal) and demographics was retrospectively collected from the patients’ clinical records and analysed. In total, 85 patients (92.4% of eligible patients) had capacity to decide if they wanted the COVID-19 vaccine. Of these 68 (80.0%) consented and 17 (20.0%) declined to consent. A similar proportion of patients aged under and over 40 years old consented to have the vaccine. Those from a Black Asian minority ethnic background were more likely to decline the vaccine than White British patients. The reasons for capacitous refusal appeared similar to those seen in the general population.

BACKGROUND Antisocial personality disorder (AsPD) is associated with poor mental health, criminality, substance use and relationship difficulties. This review updates Gibbon 2010 (previous version of the review). OBJECTIVES To evaluate the potential benefits and adverse effects of psychological interventions for adults with AsPD. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, 13 other databases and two trials registers up to 5 September 2019. We also searched reference lists and contacted study authors to identify studies. SELECTION CRITERIA Randomised controlled trials of adults, where participants with an AsPD or dissocial personality disorder diagnosis comprised at least 75% of the sample randomly allocated to receive a psychological intervention, treatment-as-usual (TAU), waiting list or no treatment. The primary outcomes were aggression, reconviction, global state/functioning, social functioning and adverse events. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS This review includes 19 studies (eight new to this update), comparing a psychological intervention against TAU (also called 'standard Maintenance'(SM) in some studies). Eight of the 18 psychological interventions reported data on our primary outcomes. Four studies focussed exclusively on participants with AsPD, and 15 on subgroups of participants with AsPD. Data were available from only 10 studies involving 605 participants. Eight studies were conducted in the UK and North America, and one each in Iran, Denmark and the Netherlands. Study duration ranged from 4 to 156 weeks (median = 26 weeks). Most participants (75%) were male; the mean age was 35.5 years. Eleven studies (58%) were funded by research councils. Risk of bias was high for 13% of criteria, unclear for 54% and low for 33%. Cognitive behaviour therapy (CBT) + TAU versus TAU One study (52 participants) found no evidence of a difference between CBT + TAU and TAU for physical aggression (odds ratio (OR) 0.92, 95% CI 0.28 to 3.07; low-certainty evidence) for outpatients at 12 months post-intervention. One study (39 participants) found no evidence of a difference between CBT + TAU and TAU for social functioning (mean difference (MD) -1.60 points, 95% CI -5.21 to 2.01; very low-certainty evidence), measured by the Social Functioning Questionnaire (SFQ; range = 0-24), for outpatients at 12 months post-intervention. Impulsive lifestyle counselling (ILC) + TAU versus TAU One study (118 participants) found no evidence of a difference between ILC + TAU and TAU for trait aggression (assessed with Buss-Perry Aggression Questionnaire-Short Form) for outpatients at nine months (MD 0.07, CI -0.35 to 0.49; very low-certainty evidence). One study (142 participants) found no evidence of a difference between ILC + TAU and TAU alone for the adverse event of death (OR 0.40, 95% CI 0.04 to 4.54; very low-certainty evidence) or incarceration (OR 0.70, 95% CI 0.27 to 1.86; very low-certainty evidence) for outpatients between three and nine months follow-up. Contingency management (CM) + SM versus SM One study (83 participants) found evidence that, compared to SM alone, CM + SM may improve social functioning measured by family/social scores on the Addiction Severity Index (ASI; range = 0 (no problems) to 1 (severe problems); MD -0.08, 95% CI -0.14 to -0.02; low-certainty evidence) for outpatients at six months. 'Driving whilst intoxicated' programme (DWI) + incarceration versus incarceration One study (52 participants) found no evidence of a difference between DWI + incarceration and incarceration alone on reconviction rates (hazard ratio 0.56, CI -0.19 to 1.31; very low-certainty evidence) for prisoner participants at 24 months. Schema therapy (ST) versus TAU One study (30 participants in a secure psychiatric hospital, 87% had AsPD diagnosis) found no evidence of a difference between ST and TAU for the number of participants who were reconvicted (OR 2.81, 95% CI 0.11 to 74.56, P = 0.54) at three years. The same study found that ST may be more likely to improve social functioning (assessed by the mean number of days until patients gain unsupervised leave (MD -137.33, 95% CI -271.31 to -3.35) compared to TAU, and no evidence of a difference between the groups for overall adverse events, classified as the number of people experiencing a global negative outcome over a three-year period (OR 0.42, 95% CI 0.08 to 2.19). The certainty of the evidence for all outcomes was very low. Social problem-solving (SPS) + psychoeducation (PE) versus TAU One study (17 participants) found no evidence of a difference between SPS + PE and TAU for participants' level of social functioning (MD -1.60 points, 95% CI -5.43 to 2.23; very low-certainty evidence) assessed with the SFQ at six months post-intervention. Dialectical behaviour therapy versus TAU One study (skewed data, 14 participants) provided very low-certainty, narrative evidence that DBT may reduce the number of self-harm days for outpatients at two months post-intervention compared to TAU. Psychosocial risk management (PSRM; 'Resettle') versus TAU One study (skewed data, 35 participants) found no evidence of a difference between PSRM and TAU for a number of officially recorded offences at one year after release from prison. It also found no evidence of difference between the PSRM and TAU for the adverse event of death during the study period (OR 0.89, 95% CI 0.05 to 14.83, P = 0.94, 72 participants (90% had AsPD), 1 study, very low-certainty evidence). AUTHORS' CONCLUSIONS There is very limited evidence available on psychological interventions for adults with AsPD. Few interventions addressed the primary outcomes of this review and, of the eight that did, only three (CM + SM, ST and DBT) showed evidence that the intervention may be more effective than the control condition. No intervention reported compelling evidence of change in antisocial behaviour. Overall, the certainty of the evidence was low or very low, meaning that we have little confidence in the effect estimates reported. The conclusions of this update have not changed from those of the original review, despite the addition of eight new studies. This highlights the ongoing need for further methodologically rigorous studies to yield further data to guide the development and application of psychological interventions for AsPD and may suggest that a new approach is required.

OBJECTIVE:Outcomes for any mental health service will vary with the characteristics of those admitted as well as with the clinical provision of the service itself. This study aims to explore, for a medium secure forensic service in England, temporal changes in (1) characteristics of those admitted and (2) outcome after discharge and (3) to examine whether such changes are related.METHOD:Baseline characteristics and reconviction outcomes were derived from multiple data sources for 550 first admissions to a medium secure forensic unit for a 20-year period. Time to reconviction was examined using Kaplan-Meier analysis and Cox regression.RESULTS:Over time, severity of admissions increased, as did discharges to prison; discharges to non-secure hospitals reduced. Risk of reconviction increased by 3.9%-4.2% for each year of admission from 1983, which was explained by the increased admission of higher-risk patients.CONCLUSION:This medium secure service admitted patients with increasing levels of risk; reoffending rates reflect admission characteristics. Service funding decisions should take account of the characteristics of those admitted.SIGNIFICANT OUTCOMES:This study indicates that the profile of patients admitted over a 20-year period increased in severity. Over time, reconviction after discharge occurred earlier after release. This increase in reconviction was explained by the type of patient admitted.LIMITATIONS:Examination of a cohort from a single medium secure unit limits the generalizability of the findings. The study focuses on a criminological outcome measure (i.e. reconviction); other domains may be equally relevant (e.g. the relief of psychological distress). Examining an entire series of admissions introduces heterogeneity by, for example, considering the outcome of men and women together.

BackgroundThe use of additional sedative psychotropic medication to calm agitated or aggressive patients is known as rapid tranquillisation (RT). Several studies of RT practice have been conducted in psychiatric intensive care units (PICUs) and acute psychiatric settings.MethodWe carried out a cross-sectional survey of the use of parental sedation in an English secure hospital using data from medication charts and case notes.ResultsWe studied the medication charts of 316 patients and found 203 incidents (all involving intramuscular route) of parenteral sedation involving just 35 patients. The vast majority (30; 85.7%) of those administered parenteral sedation were female and most (23; 65.7%) had emotionally unstable personality disorder. The most common indication was self-harm (44; 21.7%). In 24 (11.8%) instances the patient had requested an injection. A single drug was administered in 159 (78.3%) cases. The most commonly administered drug was lorazepam (152 cases) followed by haloperidol (69) and olanzapine (21). Case note documentation was frequently inadequate and in very few cases was there evidence of physical monitoring.ConclusionsThe use of parenteral sedation was rather different from that previously described in PICUs. Hospital policy and NICE guidance were not always being followed. Measures to rectify these deficits are being taken.

This is the protocol for a review and there is no abstract. The objectives are as follows: This review aims to evaluate the potential beneficial and adverse effects of psychological interventions for people with avoidant personality disorder.

Serious adverse incidents in secure psychiatric hospitals are infrequent but significant events. The frequency and characteristics of escape, absconsion, homicide and suicide in English high-secure hospitals have been described, but no research has been dedicated to hostage-taking. In this study, we collected details about all hostage-taking incidents in one high-secure hospital, Rampton Hospital, over a 25-year period (1984–2009). We identified four incidents. All were perpetrated by male patients. In two cases, the victims were female staff and in the other two cases, the victims were male patients. All incidents were planned; two involved the use of a weapon. None of the incidents was driven by acute symptoms of mental illness. None resulted in serious injury or in prosecution. Three patients had a history of hostage-taking. Whilst hostage-taking is a serious event, it is extremely rare and appears to be successfully managed in a highly structured and well-staffed environment.