In this chapter we enlarge the sampling information considered so far by adding to the data of cost and effectiveness of every patient a set of patient covariates. The covariates indicate certain deterministic physical characteristics of the patient such as age, sex, health status, and semiological variables of the disease. The optimal treatment for the whole patient population is typically suboptimal for subgroups, and hence the adaptation of the cost-effectiveness analysis to this situation is of interest and yields the cost-effectiveness analysis for subgroups. Since the definition of patient subgroups is made in terms of the set of covariates it is important to exclude those covariates that do not have an influence on the disease. This means that for carrying out a cost-effectiveness analysis for subgroups a previous step should be the statistical detection of the influential covariates from the original set of them. A …

Background: Attention-deficit/hyperactivity disorder (ADHD) is a highly prevalence disorder, seen in 20-30% of young adult prisoners. Pharmacoepidemiological studies, a small randomised controlled, and open trial data suggest clinically significant reductions in ADHD symptoms, emotional dysregulation, disruptive behaviour and engagement with educational activities. Yet, routine treatment of ADHD in offenders with ADHD is not yet established clinical practice. There is continued uncertainty about the clinical response to methylphenidate, a first line treatment for ADHD, in offenders who often present with an array of complex mental health problems that may better explain states of inattentive, overactive restless and impulsive behaviours. To address this problem we conduct an efficacy trial to establish the short term effects of OROS-methylphenidate (Concerta XL), an extended release formulation of MPH, on ADHD symptoms, emotional dysregulation and behaviour. Methods: Parallel arm randomised placebo-controlled trial of OROS-MPH on ADHD symptoms, behaviour and functional outcomes in young male prisoners aged 16-25, meeting DSM-5 criteria for ADHD. Participants are randomised to 8-weeks treatment with OROS-MPH or placebo, titrated over 5 weeks to balance ADHD symptom improvement against side effects. 200 participants will be recruited with 1:1 ratio of drug to placebo. The primary outcome is change in level of ADHD symptoms after 8-weeks of trial medication. Discussion: Potential benefits include improvement in ADHD symptoms, emotional dysregulation, attitudes towards violence, critical incidents and engagement with educational and rehabilitation programs. Demonstrating efficacy and safety of MPH on ADHD symptoms and associated impairments may provide the data needed to develop effective healthcare pathways for a significant group of young offenders. Establishing efficacy of MPH in this population will provide the foundation needed to establish long term effectiveness studies with the potential for demonstrating significant reductions in criminal behaviour and improved health-economic outcomes. Trial Registration: ISRCTN16827947l; EudraCT Number: 2015-004271-78. Protocol version: v2.0 30.08.2018

Background: The recall of conditionally discharged forensic patients in England is a formal order from the Ministry of Justice under the Mental Health Act (1983) which has the power to revoke conditional release and direct readmission to hospital. Recall has significant implications for the individual and for hospital services, but despite this, little is known about predictors of recall for forensic patients. Methods: We examined the rate of recall for 101 patients conditionally discharged from medium secure forensic inpatient services between 2007 and 2013. Demographic, clinical, and forensic factors were examined as possible predictors of time to recall using Cox regression survival techniques. Results: Conditionally discharged patients were followed for an average of 811 days, during which 45 (44.5%) were recalled to hospital. Younger age (HR 1.89; 95% CI 1.02-3.49; p = 0.04), non-white ethnicity (HR 3.44; 95% CI 1.45-8.13), substance abuse history (HR 2.52; 95% CI 1.17-5.43), early violence (HR 1.90; 95% CI 1.03-3.50), early childhood maladjustment (HR 1.92; 95% CI 1.01-3.68), treatment with a depot medication (HR 2.17; 95% CI 1.14-4.11), being known to mental health services (HR 3.44; 95% CI 1.06-11.16), and a psychiatric admission prior to the index admission (HR 2.44; 95% CI 1.08-5.52) were significantly associated with a shorter time to recall. Treatment with clozapine reduced the risk of recall to hospital (HR 0.40; 95% CI 0.20-0.79). Conclusions: Time to recall can be predicted by a range of factors that are readily available to clinical teams. Further research is required to determine if targeted interventions can modify the likelihood or time to recall for conditionally releasedforensic patients. (c) 2017 Elsevier Masson SAS. All rights reserved.

Previous studies have investigated factors associated with outcome at Mental Health Review Tribunals (MHRTs) in forensic psychiatric patients; however, dynamic variables such as treatment compliance and substance misuse have scarcely been examined, particularly in UK samples. We aimed to determine whether dynamic factors related to behaviour, cooperation with treatment, and activities on the ward were prospectively associated with outcome at MHRT.

This chapter examines community psychiatric service provision for mentally disordered offenders, focussing on the United Kingdom and United States. In doing so, it acknowledges that mentally disordered offenders are at risk of rejection and of falling between services. They are doubly stigmatized by having a mental illness and being offenders. It explores the context, commissioning, components of a service, and models of care (including the evidence base for them). Also considered are the pros and cons of specialist services, as well as how they might differentiate their task from that of the CMHT. The chapter concludes by considering how services can work together to meet the needs of this complex and challenging group of patients.

Novel technological interventions are increasingly used in mental health settings. In this article, we describe 3 novel technological strategies in use for management of risk and violence in 2 forensic psychiatry settings in the United Kingdom: electronic monitoring by GPS-based tracking devices of patients on leave from a medium secure service in London, and closed circuit television (CCTV) monitoring and motion sensor technology at Broadmoor high secure hospital. A common theme is the use of these technologies to improve the completeness and accuracy of data used by clinicians to make clinical decisions. Another common thread is that each of these strategies supports and improves current clinical approaches rather than drastically changing them. The technologies offer a broad range of benefits. These include less restrictive options for patients, improved accountability of both staff and patients, less invasive testing, improved automated record-keeping, and better assurance reporting. Services utilizing technologies need also be aware of limitations. Technologies may be seen as unduly restrictive by patients and advocates, and technical issues may reduce effectiveness. It is vital that the types of technological innovations described in this article should be subject to thorough evaluation that addresses cost effectiveness, qualitative analysis of patients' attitudes, safety, and ethical considerations.

Background Incidents of absconsion in forensic psychiatric units can have potentially serious consequences, yet surprisingly little is known about the characteristics of patients who abscond from these settings. The few previous studies conducted to date have employed retrospective designs, and no attempt has been made to develop an empirically-derived risk assessment scale. In this prospective study, we aimed to identify predictors of absconsion over a two-year period and investigate the feasibility of developing a brief risk assessment scale. Methods The study examined a representative sample of 135 patients treated in forensic medium- and low-secure wards. At baseline, demographic, clinical, treatment-related, and offending/behavioural factors were ascertained from electronic medical records and the treating teams. Incidents of absconsion (i.e., failure to return from leave, incidents of escape, and absconding whilst on escorted leave) were assessed at a two-year follow-up. Logistic regression analyses were used to determine the strongest predictors of absconsion which were then weighted according to their ability to discriminate absconders and non-absconders. The predictive utility of a brief risk assessment scale based on these weighted items was evaluated using receiver operator characteristics (ROC). Results During the two-year follow-up period, 27 patients (20%) absconded, accounting for 56 separate incidents. In multivariate analyses, four factors relating to offending and behaviour emerged as the strongest predictors of absconsion: history of sexual offending, previous absconsion, recent inpatient verbal aggression, and recent inpatient substance use. The weighted risk scale derived from these factors had moderate-to-good predictive accuracy (ROC area under the curve: 0.80; sensitivity: 067; specificity: 0.71), a high negative predictive value (0.91), but a low positive predictive value (0.34). Conclusion Potentially-targetable recent behaviours, such as inpatient verbal aggression and substance use, are strong predictors of absconsion in forensic settings; the absence of these factors may enable clinical teams to identify unnecessarily restricted low-risk individuals.

Amnesia for violent offenses is common, but little is known about underlying causes or whether memory can recover. In this study, 50 violent offenders were interviewed with neuropsychological and psychometric measures, to determine the factors that underlie amnesia and the recovery of memory in these cases. The results showed that amnesia for a violent offense was associated with crimes of passion and dissociative symptoms at the time, but not with impaired neuropsychological functioning. Long amnesic gaps were associated with a state of dissociation surrounding the offense and with previous blackouts (whether alcoholic or dissociative). Memory often recovered, either partially or completely, especially where there was a history of blackouts or a lengthy amnesic gap. Brief amnesic gaps were likely to persist, perhaps as a consequence of faulty encoding during a period of extreme emotional arousal (or red-out).

Screening for mental health problems on reception into custody has been criticised. However, there have been few studies on care pathways through custody as a result of screening identification. We aimed to identify what actions were taken as a result of screening positive for suicidal ideation and mental health problems. Case records for 2166 prisoners newly received into five prisons in England and documented contact with health care professionals in the following month were examined by hand over a four-month period. Altogether, 3% of prisoners were screened as having current suicidal ideas, of whom 30% had no contact with mental health services or risk assessment documentation. Another 21% of new receptions received psychotropic medication, for whom over 60% received no primary mental health assessment, and only 36% received psychotropic medication in prison. Care pathways need to be defined, and screening needs to be delivered as originally intended by initial screen for life-threatening matters, followed by a later, comprehensive assessment of health needs.

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Background Violent off ending by veterans of the Iraq and Afghanistan conflicts is a cause for concern and there is much public debate about the proportion of ex-military personnel in the criminal justice system for violent offences. Although the psychological effects of conflict are well documented, the potential legacy of violent off ending has yet to be ascertained. We describe our use of criminal records to investigate the effect of deployment, combat, and post-deployment mental health problems on violent off ending among military personnel relative to pre-existing risk factors.Methods In this cohort study, we linked data from 13 856 randomly selected, serving and ex-serving UK military personnel with national criminal records stored on the Ministry of Justice Police National Computer database. We describe off ending during the lifetime of the participants and assess the risk factors for violent off ending.Findings 2139 (weighted 17.0%) of 12 359 male UK military personnel had a criminal record for any offence during their lifetime. Violent off enders (1369 [11.0%]) were the most prevalent off ender types; prevalence was highest in men aged 30 years or younger (521 [20.6%] of 2728) and fell with age (164 [4.7%] of 3027 at age >45 years). Deployment was not independently associated with increased risk of violent off ending, but serving in a combat role conferred an additional risk, even after adjustment for confounders (violent off ending in 137 [6.3%] of 2178 men deployed in a combat role vs 140 (2.4%) of 5797 deployed in a non-combat role; adjusted hazard ratio 1.53, 95% CI 1.15-2.03; p=0.003). Increased exposure to traumatic events during deployment also increased risk of violent off ending (violent off ending in 104 [4.1%] of 2753 men with exposure to two to four traumatic events vs 56 [1.6%] of 2944 with zero to one traumatic event, 1.77, 1.21-2.58, p=0.003; and violent off ending in 122 [5.1%] of 2582 men with exposure to five to 16 traumatic events, 1.65, 1.12-2.40, p=0.01; test for trend, p=0.032). Violent off ending was strongly associated with post-deployment alcohol misuse (violent off ending in 120 [9.0%] of 1363 men with alcohol misuse vs 155 [2.3%] of 6768 with no alcohol misuse; 2.16, 1.62-2.90; p<0.0001), post-traumatic stress disorder (violent off ending in 25 [8.6%] of 344 men with post-traumatic stress disorder vs 221 [3.0%] of 7256 with no symptoms of post-traumatic stress disorder; 2.20, 1.36-3.55; p=0.001), and high levels of self-reported aggressive behaviour (violent off ending in 56 [6.7%] of 856 men with an aggression score of six to 16 vs 22 [1.2%] of 1685 with an aggression score of zero; 2.47, 1.37-4.46; p=0.003). Of the post-traumatic stress disorder symptoms, the hyperarousal cluster was most strongly associated with violent off ending (2.01, 1.50-2.70; p<0.0001).Interpretation Alcohol misuse and aggressive behaviour might be appropriate targets for interventions, but any action must be evidence based. Post-traumatic stress disorder, though less prevalent, is also a risk factor for violence, especially hyperarousal symptoms, so if diagnosed it should be appropriately treated and associated risk monitored.

Background. Children with conduct disorder (CD) are at increased risk of developing antisocial personality disorder (ASPD) and psychopathy in adulthood. The biological basis for this is poorly understood. A preliminary diffusion tensor magnetic resonance imaging (DT-MRI) study of psychopathic antisocial adults reported significant differences from controls in the fractional anisotropy (FA) of the uncinate fasciculus (UF), a white-matter tract that connects the amygdala to the frontal lobe. However, it is unknown whether developmental abnormalities are present in the UF of younger individuals with CD.Method. We used DT-MRI tractography to investigate, for the first time, the microstructural integrity of the UF in adolescents with CD, and age-related differences in this tract. We compared FA and perpendicular diffusivity of the UF in 27 adolescents with CD and 16 healthy controls (12 to 19 years old) who did not differ significantly in age, IQ or substance use history. To confirm that these findings were specific to the UF, the same measurements were extracted from two non-limbic control tracts. Participants in the CD group had a history of serious aggressive and violent behaviour, including robbery, burglary, grievous bodily harm and sexual assault.Results. Individuals with CD had a significantly increased FA (p=0.006), and reduced perpendicular diffusivity (p=0.002), in the left UF. Furthermore, there were significant age-related between-group differences in perpendicular diffusivity of the same tract (Z(obs)=2.40, p=0.01). Controls, but not those with CD, showed significant age-related maturation. There were no significant between-group differences in any measure within the control tracts.Conclusions. Adolescents with CD have significant differences in the 'connectivity' and maturation of UF.

Personality disorders are common conditions that place a significant burden on the individual sufferer, their carers, and wider society. Patients with personality disorder can be complex to manage and co-morbid personality disorder can impact adversely on the treatment and prognosis of other disorders. Therapeutic advances and changing expectations of healthcare commissioners now challenge the previous reluctance of doctors to engage these patients in treatment, and Department of Health policy emphasizes that service providers must address the needs of this patient population. Despite previous pessimism regarding the treatability of personality disorder, there is a growing body of literature supporting the efficacy of various treatment approaches, especially for problematic behaviours such as self-harming. This article reviews the epidemiology, diagnosis, clinical presentation, assessment and management of personality disorders.

Background There is considerable media, political and public interest on both sides of the Atlantic in an alleged rise in violence among military personnel returned from conflicts in Iraq and Afghanistan. This study explores violence among a large sample of UK military personnel, a proportion of whom had been deployed to Iraq/Afghanistan. The aims were to estimate the prevalence of self-reported violence, examine the impact of deployment and combat experiences on subsequent violence and the association with post-deployment mental health problems and alcohol misuse. Methods This study formed part of a questionnaire-based cohort study established to explore the impact of deployment on mental health among UK military personnel. The sample was randomly selected from all military personnel serving in the UK Armed Forces between 2003 and 2007. A total of 9986 participants from all Services were included, some had been deployed and some had been trained but not deployed. Special Forces were excluded. Data, collected by questionnaire, included information on deployment experiences, socio-demographic and military characteristics, pre-enlistment antisocial behaviour, and post-deployment health outcomes. The main violence outcomes were self –report measures of interpersonal violence. Results 6.2% of the sample reported interpersonal violence in the last month. Deployment showed a stronger association with subsequent violence among reservists (OR=2.98 (1.50–5.93),P=0.002) than among regulars (OR=1.26 (0.96–1.67),P=0.098) when compared to their non-deployed counterparts. Performing a combat role whilst deployed was associated with a significantly increased likelihood of violence among regulars (OR=1.90 (1.38–2.75), P<0.001) and the risk of violence increased with the number of traumatic events experienced (P<0.001)). Violence on homecoming was also associated with mental health problems such as PTSD (OR=4.8 (3.2–7.2) P<0.001) and alcohol misuse (OR=3.1 (2.5–3.9) P<0.001). Conclusion Military deployment, in particular combat exposure, increased the risk of subsequent violence among military personnel and the risk of violence increased with increasing number of traumatic events experienced on deployment. Valuable information on risk factors for violence among military personnel is provided, especially regarding increased risk among deployed reservists and among personnel who report post-deployment mental health problems and alcohol misuse.

The trial of Anders Breivik, who murdered 77 people in two attacks in Norway, has attracted considerable controversy because of the questions concerning his mental state. Max Taylor (doi:10.1136/bmj.e4612) argues that such extreme fanatics should be considered insane, but Tom Fahy believes that a psychiatric diagnosis is an abrogation of personal and societal responsibility

When a delayed matching-to-sample task does not involve short-delay trials interspersed among the long-delay trials, there is evidence that pigeons show long latencies in responding to the sample (sample observing response). They may even stop responding altogether. Two experiments were conducted to confirm the phenomenon and determine what aspect of the procedure is responsible for it. In Experiment 1 pigeons were trained on a delayed matching-to-sample task in which the delay remined constant throughout each session and was increased as each bird reached a performance criterion. The results indicated that sampleresponse latency increased in a regular fashion as delay increased. When the delay increased to 8.0 s, responding to the sample often stopped for long periods of time. In Experiment 2 pigeons were exposed to constant delay sessions (LONG), or mixed delay sessions with the delay length signaled (COR) or unsignaled (UNC). Sample-response latencies increased with increasing delay on long-delay trials for the LONG and the COR groups but not for the UNC group. Results supported the hypothesis that predictability of the long delay and not the loss of association between sample responses and reinforcement was responsible for the increased sample-response latency.

Purpose Concern has been raised over alleged increases in antisocial behaviour by military personnel returning from the deployment in Iraq and Afghanistan. US-based research has shown that post-deployment violence is related not only to combat experience, but also to pre-enlistment antisocial behaviour (ASB). This study aimed to examine the association between pre-enlistment ASB and later behavioural outcomes, including aggression, in a large randomly selected UK military cohort. Methods Baseline data from a cohort study of 10,272 UK military personnel in service at the time of the Iraq war in 2003 were analysed. The associations between pre-enlistment ASB and a range of socio-demographic and military variables were examined as potential confounders. Logistic regression analyses were performed to examine the relationship between pre-enlistment ASB and military behavioural outcomes such as severe alcohol use, violence/aggression and risk-taking behaviour, controlling for confounders. Results 18.1% were defined as having displayed pre-enlistment ASB. Pre-enlistment ASB was significantly associated with factors such as younger age, low educational achievement, male gender, non-officer rank, Army personnel, being a regular, increasing time spent on the deployment and having a combat role. Pre-enlistment ASB was associated with increased risk of negative behavioural outcomes (severe alcohol misuse, outbursts of anger or irritability, fighting or assaultative behaviour and risk-taking behaviour), after controlling for confounders, suggesting that such background information may identify individuals who are more vulnerable to subsequent behavioural disturbance. Conclusion The results of this study suggest that those already demonstrating ASB prior to joining the military are more likely to continue on this trajectory, thus emphasising the importance of considering pre-enlistment behaviour when exploring the aetiology of aggression in military personnel.

Objective: Despite a large evidence base indicating that cognitive skills programs can reduce reoffending in individuals without mental illness, there have been no randomized controlled trials (RCTs) to determine their effectiveness in mentally disordered offenders (MDOs). In the first RCT of a cognitive skills program for MDOs, we aimed to investigate whether participation in the Reasoning and Rehabilitation (R&R) program reduced violence and antisocial behavior in this population. Method: Eighty-four male inpatients with a psychotic disorder and a history of violence were recruited from medium secure forensic hospitals. Participants were randomized to receive the R&R program, consisting of 36 two-hour sessions, or treatment as usual (TAU). Incidents of violence and antisocial behavior (verbal aggression, substance use, and leave violations) were assessed during treatment and at 12-months posttreatment. Results: Relative to the TAU group, incident rates of verbal aggression and leave violations during the treatment period were significantly lower in the R&R group; the effect on verbal aggression was maintained at 12-months posttreatment. Half of those randomized to receive R&R did not Complete treatment; post hoc analyses were therefore conducted to compare treatment responses in program completers and noncompleters. After controlling for psychopathic traits, incidents of violence, verbal aggression, and leave violations during treatment were significantly lower in program completers, and there were significant effects of program completion on verbal aggression and substance use at 12-months posttreatment. Conclusions: R&R leads to a reduction in incidents of antisocial behavior in MDO populations, with potentially greater impact on those who complete treatment.