Traumatic brain injury is highly associated with self-reported childhood trauma within a juvenile offender cohort.

PRIMARY OBJECTIVE: To identify correlates of past traumatic brain injury (TBI) in a population of young offenders. RESEARCH DESIGN: Cross-sectional analyses were conducted on available data from a sample derived from the NSW Young People on Community Orders Health Survey. PROCEDURES: Study participants were administered questionnaires to collect history relating to past TBI, childhood trauma, substance abuse, and psychological/psychiatric symptoms and underwent assessments of intellectual functioning. Information on offending history was accessed through Juvenile Justice administrative records. OUTCOMES AND RESULTS: Analyses were undertaken on data from 788 young offenders (672 males and 116 females). A past TBI was reported in 39%. Symptoms of psychological distress were more prevalent in females. A history of TBI was associated with more symptoms on a Childhood Trauma Questionnaire, as well as higher psychological distress (K-10), and higher levels on standardized measures of anger/violence, post-traumatic stress, and substance abuse. CONCLUSIONS: The experience of early life trauma warrants further consideration as an antecedent to both childhood TBI and offending which might account for some of the previously observed association of mild TBI with subsequent offending behavior.

Automated Analysis of Domestic Violence Police Reports to Explore Abuse Types and Victim Injuries: Text Mining Study.

BACKGROUND: The police attend numerous domestic violence events each year, recording details of these events as both structured (coded) data and unstructured free-text narratives. Abuse types (including physical, psychological, emotional, and financial) conducted by persons of interest (POIs) along with any injuries sustained by victims are typically recorded in long descriptive narratives. OBJECTIVE: We aimed to determine if an automated text mining method could identify abuse types and any injuries sustained by domestic violence victims in narratives contained in a large police dataset from the New South Wales Police Force. METHODS: We used a training set of 200 recorded domestic violence events to design a knowledge-driven approach based on syntactical patterns in the text and then applied this approach to a large set of police reports. RESULTS: Testing our approach on an evaluation set of 100 domestic violence events provided precision values of 90.2% and 85.0% for abuse type and victim injuries, respectively. In a set of 492,393 domestic violence reports, we found 71.32% (351,178) of events with mentions of the abuse type(s) and more than one-third (177,117 events; 35.97%) contained victim injuries. "Emotional/verbal abuse" (33.46%; 117,488) was the most common abuse type, followed by "punching" (86,322 events; 24.58%) and "property damage" (22.27%; 78,203 events). "Bruising" was the most common form of injury sustained (51,455 events; 29.03%), with "cut/abrasion" (28.93%; 51,284 events) and "red marks/signs" (23.71%; 42,038 events) ranking second and third, respectively. CONCLUSIONS: The results suggest that text mining can automatically extract information from police-recorded domestic violence events that can support further public health research into domestic violence, such as examining the relationship of abuse types with victim injuries and of gender and abuse types with risk escalation for victims of domestic violence. Potential also exists for this extracted information to be linked to information on the mental health status.

Individual- and Population-Level Impacts of Traumatic Brain Injury and Maternal Characteristics on Subsequent Offending Behavior.

OBJECTIVE: To evaluate the individual- and population-level impact of a combination of factors, including traumatic brain injury (TBI) and certain maternal characteristics, on subsequent criminal conviction. DESIGN AND PARTICIPANTS: A retrospective record linkage study involving a cohort of 30 599 individuals born between 1980 and 1985, with ratio of 1 (with TBI): 3 (no TBI), matched by sex and the year of birth. METHODS AND PROCEDURES: Cox proportional hazard regression models and population attributable risk percentages (PAR%) were used to assess the contribution of TBI and other risk factors on subsequent criminal convictions. MAIN OUTCOMES AND RESULTS: Overall, individuals born to the teenaged mothers (<20 years) have significantly higher proportion of TBI than those born to older mothers (35% vs 22%; P < .001). In the gender-specific analyses, a history of TBI was associated with increased risk for criminal convictions (adjusted hazard ratio [aHR]: 1.48, 95% confidence interval [CI]: 1.36-1.60, and aHR: 1.45, 95% CI: 1.22-1.73, for men and women, respectively). Maternal characteristics (maternal age, single parent, multiparity) were identified as the greater contributor to the criminal convictions (PAR%: 57% and 67% for men and women, respectively). The combined impact of mental illness, maternal factors, and TBI was estimated to be 67% and 74% (for men and women, respectively); with nonoverlapping 95% CIs for PAR%, these factors were estimated to have had a higher impact among females than among males. CONCLUSION: More than half of the criminal convictions were associated with a relatively small number of risk factors, including poor mental health, low socioeconomic status, and TBI as well as certain maternal characteristics.

Anxiety Levels Are Independently Associated With Cognitive Performance in an Australian Multiple Sclerosis Patient Cohort.

Neurological and psychological symptoms in multiple sclerosis can affect cognitive function. The objective of this study was to explore the relationship between psychological measures and cognitive performance in a patient cohort. In 322 multiple sclerosis patients, psychological symptoms were measured using the Depression Anxiety and Stress Scale, and cognitive function was evaluated using Audio Recorded Cognitive Screen. Multifactor linear regression analysis, accounting for all clinical covariates, found that anxiety was the only psychological measure to remain a significant predictor of cognitive performance (p<0.001), particularly memory function (p<0.001). Further prospective studies are required to determine whether treatment of anxiety improves cognitive impairment.

MR Spectroscopy Findings in Retired Professional Rugby League Players.

The aim of this study was to examine brain neurometabolite concentrations in retired rugby league players who had a history of numerous self-reported concussions. Participants were 16 retired professional rugby league players (ages 30-45 years) with an extensive history of concussion and participation in contact sports, and 16 age- and education-matched controls who had no history of neurotrauma or participation in contact sports. All completed a clinical interview, psychological and cognitive testing, and magnetic resonance spectroscopy (MRS) investigation. MRS voxels were placed in posterior cingulate grey matter and parietal white matter. Neurometabolite concentrations were quantified using LCModel. It was hypothesized that retired athletes would differ on N-acetyl aspartate, myo-inositol, choline, glutamate, and glutathione. Retired players had significantly lower concentrations of grey matter glutathione (p=0.02, d=0.91). They did not significantly differ in concentrations of other neurometabolites. There were no significant differences between groups on measures of depression, anxiety, or cognitive functioning. The retired athletes reported significantly greater alcohol use (p<0.01; Cohen's d=1.49), and they had worse manual dexterity using their non-dominant hand (p=0.03; d=1.08). These preliminary findings suggest that MRS might be modestly sensitive to biochemical differences in athletes after their athletic careers have ended in the absence of clinical differences in cognitive performance and self-reported psychological functioning.

A systematic review of concussion in rugby league.

OBJECTIVES: Concussion remains one of the inherent risks of participation in rugby league. While other injuries incurred by rugby league players have been well studied, less focus and attention has been directed towards concussion. REVIEW METHOD: The current review examined all articles published in English from 1900 up to June 2013 pertaining to concussion in rugby league players. DATA SOURCES: Publications were retrieved via six databases using the key search terms: rugby league, league, football; in combination with injury terms: athletic injuries, concussion, sports concussion, sports-related concussion, brain concussion, brain injury, brain injuries, mild traumatic brain injury, mTBI, traumatic brain injury, TBI, craniocerebral trauma, head injury and brain damage. Observational, cohort, correlational, cross-sectional and longitudinal studies were all included. RESULTS: 199 rugby league injury publications were identified. 39 (20%) were related in some way to concussion. Of the 39 identified articles, 6 (15%) had the main aim of evaluating concussion, while the other 33 reported on concussion incidence as part of overall injury data analyses. Rugby league concussion incidence rates vary widely from 0.0 to 40.0/1000 playing hours, depending on the definition of injury (time loss vs no time loss). The incidence rates vary across match play versus training session, seasons (winter vs summer) and playing position (forwards vs backs). The ball carrier has been found to be at greater risk for injury than tacklers. Concussion accounts for 29% of all injuries associated with illegal play, but only 9% of injuries sustained in legal play. CONCLUSIONS: In comparison with other collision sports, research evaluating concussion in rugby league is limited. With such limited published rugby league data, there are many aspects of concussion that require attention, and future research may be directed towards these unanswered questions.

Application of the Audio Recorded Cognitive Screen and its relation to functioning in schizophrenia.

OBJECTIVE: This study investigated the ability of the Audio Recorded Cognitive Screen (ARCS) to detect cognitive deficit in individuals with schizophrenia, relative to the Mini Mental State Examination (MMSE) and the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), and explored the associations between the ARCS and functional outcomes. We hypothesised that the ARCS would be able to better discriminate between individuals with schizophrenia and healthy controls than the MMSE, and that ARCS performance would be correlated with measures of social and vocational functioning. METHODS: The participants were 19 community-dwelling individuals with schizophrenia or schizoaffective disorder and 19 healthy controls recruited from the Australian Schizophrenia Research Bank (ASRB). Participants completed the ARCS, MMSE, and self-report measures of social and vocational functioning. Clinical and diagnostic data stored by the ASRB were also utilised. RESULTS: The schizophrenia group performed worse than the control group on the ARCS, with memory, t(36)=2.49, p=0.02, 95% CI [-1.84, -18.79] and fluency, t(36)=2.40, p=0.02, 95% CI [-1.87, -22.24] domains being the main discriminating measures. The RBANS also discriminated between the two groups, and ARCS and RBANS total scores were moderately to strongly correlated. There was no difference between the two groups on the MMSE after controlling for demographic variables. ARCS performance was associated with employment status [χ2(1)=7.16, p=0.007]. CONCLUSION: The ARCS may be sensitive to the cognitive deficits in outpatients with schizophrenia and an indicator of functional outcomes in this population.

The role of olfactory challenge tests in incipient dementia and clinical trial design.

The brain changes associated with Alzheimer's disease (AD) develop slowly over many years before the onset of dementia. Biomarkers for AD that allow its detection during this clinically silent phase will be hugely important when disease-modifying treatments that halt or slow its progression become available. Early detection, leading to early treatment, may in some cases avert dementia. Biomarkers aid our understanding of the presymptomatic stages of the disease and enable the identification of individuals with early disease who, by participating in clinical trials of investigational treatments with disease-modifying potential, contribute unique and vital information necessary to evaluate novel therapies. Most currently available AD biomarkers are expensive and not widely available and there are major efforts underway to find cheaper, simpler options. The olfactory system is affected by AD and the results from simple and inexpensive tests of the sense of smell, especially when paired with other information, can help identify individuals early in the disease. We review recent literature relevant to the use of simple olfactory tests, including some novel approaches, as aids to the early detection of AD. We consider their possible role in the design and conduct of clinical trials and suggest how in the future, when more effective treatments become available, they might be integrated into screening programs for early AD detection.

Exposure to Childhood Adversity and Intimate Partner Violence in a Sample of Incarcerated Women in Australia.

Women who use violence represent one of the fastest growing groups within the Australian prisoner population, including Aboriginal women who are more likely to be incarcerated than non-Aboriginal women for violent crimes. Many incarcerated women report histories of adverse childhood experiences (ACEs) and intimate partner violence. This exploratory study examines baseline data from a sample of 167 women in 3 Western Australia women's prisons enrolled in a gender-specific violent behavior program. It describes their exposure to intimate partner violence, head injury, and childhood adversities. Overall, 94% of women had experienced at least one childhood adversity (median 6), and 94% reported being a victim of physical violence by a current or former intimate partner. Aboriginal women were more likely than non-Aboriginal women to report that a family member was incarcerated as a child (p = .001). There was an association between an increased number of ACEs and head injury with a loss of consciousness (p = .008). Overall, these results present a harrowing picture of childhood exposure to adversity and violence in adulthood. Successful rehabilitation of women incarcerated for violent crimes should be cognizant of the histories of extreme violence endured by most of these women.

Psychiatric admissions in young people after expiration of criminal justice supervision in Australia: a retrospective data linkage study.

BACKGROUND: Mental health services are available for young people involved with the criminal justice system. However, they have unmet mental health needs after the expiration of criminal justice supervision. OBJECTIVE: To determine the incidence rate and identify predictors of psychiatric hospitalisations within 24 months after the expiration of criminal justice supervision among young people involved with the New South Wales (NSW) criminal justice system. METHODS: Retrospective data from 1556 individuals aged 14-22 years who participated in four surveys of justice-involved young people in NSW were harmonised and linked to four NSW data collections. We calculated the incidence rates of psychiatric hospitalisations within 24 months postsupervision and identified predictors of these hospitalisations using a competing risks regression analysis. RESULTS: Within 24 months postsupervision, 11.4% had a psychiatric hospitalisation compared with 3.5% during supervision. 20.7% of those admitted had a known history of mental illness and engaged with community-based and outpatient mental health services postsupervision. Predictors of psychiatric hospitalisations were: female sex (adjusted subdistribution HR (asHR) 1.84, 95% CI 1.24 to 2.73); previous incarceration (highest asHR for ≥4 episodes 1.67, 95% CI 1.01 to 2.78); head injury (asHR 1.63, 95% CI 1.20 to 2.21); personality disorder (asHR 3.66, 95% CI 2.06 to 6.48) and alcohol and substance use disorder (asHR 1.89, 95% CI 1.29 to 2.77). CONCLUSION: Justice-involved youth have higher rates of psychiatric admissions after criminal justice supervision. Engagement with mental health services postsupervision is important in addressing emerging or persisting mental health needs.

Mortality, Criminal Sanctions, and Court Diversion in People With Psychosis.

Importance: People living with psychosis experience excess premature mortality and are overrepresented in criminal legal systems, but little is known about mortality associated with criminal sanctions or diversion in this population. Objective: To examine associations of different types of recent (past 2 years) criminal sanction, including court diversion, with mortality among people with psychosis. Design, Setting, and Participants: This population-based, retrospective, data-linkage cohort study was conducted using 6 routinely collected administrative data collections from New South Wales, Australia, relating to health, court proceedings, imprisonment, and mortality. Participants (adults aged ≥18 years hospitalized for psychotic disorders) entered observation at the time of discharge from their first psychosis-related hospital admission (or their 18th birthday if aged <18 years) between July 2001 and November 2017 and were followed-up until May 2019. Data were analyzed between February 2023 and April 2024. Exposures: Recent (past 2 years) criminal sanction type, a time-varying variable with 5 categories: no recent criminal sanction, recent mental health court diversion, recent community sanction, current imprisonment, and recent prior imprisonment (ie, recent prison release). Main Outcomes and Measures: Causes of death were described, and age- and sex-specific mortality rates by recent criminal sanction type were calculated. In those younger than 65 years, Cox regression was used to examine associations of all-cause and external-cause mortality with recent criminal sanction type, adjusting for sociodemographic, health-related, and offense-related confounders. Results: The cohort included 83 071 persons (35 791 female [43.1%]; 21 208 aged 25-34 years [25.5%]; median [IQR] follow-up, 9.5 [4.8-14.2] years), of whom 25 824 (31.1%) received a criminal sanction. There were 11 355 deaths. In those aged younger than 65 years, recent mental health court diversion, community sanctions, and prior imprisonment were associated with increased hazards of all-cause and external-cause mortality compared with no recent sanction, with the largest adjusted hazard ratios (aHRs) observed for recent prior imprisonment (all-cause mortality: aHR, 1.69; 95% CI, 1.50-1.91; external-cause mortality: aHR, 2.64; 95% CI, 2.27-3.06). Conclusions and Relevance: In this cohort study of people with psychosis, recent criminal sanctions were associated with increased mortality irrespective of sanction type. These findings suggest that future research should develop strategies to improve health and safety in people with psychosis who have criminal legal system contact.

An olfactory 'stress test' may detect preclinical Alzheimer's disease.

BACKGROUND: The olfactory bulb (OB) receives extensive cholinergic input from the basal forebrain and is affected very early in Alzheimer's disease (AD). We speculated that an olfactory 'stress test' (OST), targeting the OB, might be used to unmask incipient AD. We investigated if change in olfactory performance following intranasal atropine was associated with several known antecedents or biomarkers of AD. METHODS: We measured change in performance on the University of Pennsylvania Smell Identification Test (UPSIT) in the left nostril before (20-items) and after (remaining 20-items) intranasal administration of 1 mg of atropine. We administered cognitive tests, measured hippocampal volume from MRI scans and recorded Apolipoprotein E genotype as indices relevant to underlying AD. RESULTS: In a convenience sample of 56 elderly individuals (14 probable AD, 13 cognitive impairment no dementia, 29 cognitively intact) the change in UPSIT score after atropine ('atropine effect' = AE) correlated significantly with demographically scaled episodic memory score (r = 0.57, p < 0.001) and left hippocampal volume (LHCV) (r = 0.53, p < 0.001). Among non-demented individuals (n = 42), AE correlated with episodic memory (r = 0.52, p < 0.001) and LHCV (r = 0.49, p < 0.001) and hierarchical linear regression models adjusted for age, gender, education, and baseline UPSIT showed that the AE explained more variance in memory performance (24%) than did LHCV (15%). The presence of any APOE ϵ4 allele was associated with a more negative AE (p = 0.014). CONCLUSIONS: The OST using atropine as an olfactory probe holds promise as a simple, inexpensive screen for early and preclinical AD and further work, including longitudinal studies, is needed to explore this possibility.

Mental health service contact following release from prison or hospital discharge in those with psychosis.

Background: An association exists between psychosis and criminal offending, which evidence suggests can be reduced by effective mental health care for this vulnerable population. However mental health services often lose contact with people after diagnosis. The association between the first episode of psychosis and criminal offending highlights the need for effective mental health care for this vulnerable population. Aims: To investigate the association between the first diagnosis of psychosis (FDP) in prison or hospital and subsequent mental health service contact following release from prison or discharge from hospital. Materials and methods: Individuals with a FDP either in prison (n = 492) or hospital setting (n = 24,910) between July 2006 and December 2011 in NSW (Australia), were followed post-release or discharge until their first mental health service contact in the community, the occurrence of an offence, death, or completion of the study period at the end of December 2012. Cox regression models were used to examine the predictors for the mental health service contacts following release or discharge. Results: Over 70% of those with a FDP in prison or hospital had a psychosis-related or any community-based mental health service contact following release or discharge between July 2006 and December 2012. Those with a FDP in prison were more likely to have no contact with mental health services than those in hospital with no prior offence record (hazard ratio, HR = 3.14, 95% CI: 2.66-3.72 and adjusted hazard ratio, aHR = 3.05, 95% CI: 2.56-3.63) within a median follow-up time of 25 days for the prison group and 26 days for hospital group. Males, individuals of Aboriginal heritage and individuals diagnosed with substance-related psychoses compared to those with schizophrenia and related psychoses were less likely to have a mental health service contact following release or discharge in both the univariable and multivariable analysis. Conclusion: This study suggests that prior offending or a previous prison episode represents a barrier to mental health service contact in the community for those with a FDP. Effective rehabilitation planning while exiting prison and discharge planning from hospital are essential to the successful reintegration of these individuals with a FDP.

Traumatic brain injury rates and sequelae: a comparison of prisoners with a matched community sample in Australia.

AIM: To compare rates of past reported traumatic brain injury (TBI) in a prisoner sample with those in a control group drawn from the same location of usual residence. METHOD: The prisoner group comprised a consecutive sample of men (n = 200) received into custody and screened by face-to-face interview. The control group comprised men (n = 200) matched for location of usual residence screened by telephone interview. Participants were asked about past TBIs and screened for drug and alcohol abuse, impulsivity and dissocial personality disorder. RESULTS: Eighty-two per cent of prisoners and 71.5% of community participants reported at least one past TBI of any severity (i.e. with or without a loss of consciousness (LOC)) and 64.5% of prisoners and 32.2% of community participants reported at least one TBI associated with a LOC. Prisoners were more likely to report persisting side-effects of TBI and were much more likely to screen positive for impulsivity and dissocial personality disorder. Multivariate analyses found no significant association between TBI frequency or severity and custody/community group membership. CONCLUSIONS: High reported rates of TBI in prisoner populations may reflect the excess of socio-demographic risk factors for TBI. Results of the current study do not support a role for TBI as causally related to criminal conduct.

Diet Quality and Cognitive Performance in Australian Adults Aged 55-85 Years: A Cross-Sectional Analysis of the Hunter Community Study Cohort.

There is a lack of evidence to determine if diet quality is associated with cognitive performance in older adults. Therefore, the aim of this study was to examine whether diet quality is associated with cognitive performance among older adults. A cross-sectional, secondary analysis of baseline data from the Hunter Community Study (HCS), comparing diet quality, measured using the Australian Recommended Food Score (ARFS), along with validated cognitive performance instruments the Audio Recorded Cognitive Screen (ARCS) and the Mini-Mental State Examination (MMSE) were undertaken in adults aged 55-85 years, living in Newcastle, NSW, Australia. Adjusted linear regression analyses showed that, compared with the lowest ARFS quintile, those in the highest quintile had an ARCS score 5.883 units greater (p < 0.001; R2 = 0.0098). Furthermore, when quintiles of ARFS score were tested against each ARCS sub-scale score, statistically significant associations were observed with the greatest effect for the Memory (ß = 4.055; p = 0.001; R2 = 0.0065) and Attention (ß = 4.136; p = 0.002; R2 = 0.0047) domains. No statistically significant associations were observed between quintiles of ARFS and MMSE score in the adjusted linear regression analyses. In conclusion, a positive association was observed between diet quality and cognitive performance within this sample of older Australian adults. Further investigation of the above association over time, when follow-up data becomes available, in longitudinal analysis is recommended.

Surveillance of Domestic Violence Using Text Mining Outputs From Australian Police Records.

In Australia, domestic violence reports are mostly based on data from the police, courts, hospitals, and ad hoc surveys. However, gaps exist in reporting information such as victim injuries, mental health status and abuse types. The police record details of domestic violence events as structured information (e.g., gender, postcode, ethnicity), but also in text narratives describing other details such as injuries, substance use, and mental health status. However, the voluminous nature of the narratives has prevented their use for surveillance purposes. We used a validated text mining methodology on 492,393 police-attended domestic violence event narratives from 2005 to 2016 to extract mental health mentions on persons of interest (POIs) (individuals suspected/charged with a domestic violence offense) and victims, abuse types, and victim injuries. A significant increase was observed in events that recorded an injury type (28.3% in 2005 to 35.6% in 2016). The pattern of injury and abuse types differed between male and female victims with male victims more likely to be punched and to experience cuts and bleeding and female victims more likely to be grabbed and pushed and have bruises. The four most common mental illnesses (alcohol abuse, bipolar disorder, depression schizophrenia) were the same in male and female POIs. An increase from 5.0% in 2005 to 24.3% in 2016 was observed in the proportion of events with a reported mental illness with an increase between 2005 and 2016 in depression among female victims. These findings demonstrate that extracting information from police narratives can provide novel insights into domestic violence patterns including confounding factors (e.g., mental illness) and thus enable policy responses to address this significant public health problem.

The effect of omega-3 long chain polyunsaturated fatty acids on aggressive behaviour in adult male prisoners: a structured study protocol for a multi-centre, double-blind, randomised placebo-controlled trial and translation into policy and practice.

BACKGROUND: Interventions to better manage aggressive behaviour and reduce recidivism are a primary concern for corrective services. Nutritional interventions to correct prisoner behaviour have been largely overlooked in the literature. Emerging evidence suggests that dietary intake influences aggressive behaviours and that nutritional supplementation with omega-3 long chain polyunsaturated fatty acids (n-3 LCPUFA) could attenuate both the severity and frequency of aggressive behaviour. METHODS: Adult male prisoners who have a history of aggressive behaviour (n = 600) will be recruited from at least 6 Correctional Centres and randomised to receive either n-3 LCPUFA or placebo supplementation for a 16-week duration. Treatment will be with either 1 g/day of n-3 LCPUFA (694 mg DHA and 397 mg EPA) or placebo capsules, which are a corn/soy oil blend and are identical in size and colour. The primary outcome measure is the Inmate Behavioural Observation Scale (IBOS): an objective measure of aggressive behaviour. Secondary outcome measures include questionnaires (including aggression, attention deficit disorder, impulsivity, depression/anxiety/stress scales), engagement in programmes, recidivism and quality of life. Baseline and post-intervention assessments include the IBOS, questionnaires and blood to measure the levels of n-3 LCPUFA. DISCUSSION: To conclusively test the potential that increasing n-3 LCPUFA intakes can improve rates of prisoner aggression and associated mental health and violence-related social system management costs, we propose an adequately powered multi-centre, double-blind, randomised controlled trial, examining the effects of n-3 LCPUFA supplementation on aggressive behaviour in adult male prisoners. If successful, this study will inform prisoner policy with respect to nutrition and by inference contribute to a broader community approach to preventative mental health practices. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry (ANZCTR) ACTRN12618001665224 . Registered on 10 October 2018.

Sertraline hydrochloride for reducing impulsive behaviour in male, repeat-violent offenders (ReINVEST): protocol for a phase IV, double-blind, placebo-controlled, randomised clinical trial.

INTRODUCTION: Considerable evidence supports an association between poor impulse control (impulsivity) and violent crime. Furthermore, impulsivity and aggression has been associated with reduced levels of serotonergic activity in the brain. Selective serotonin reuptake inhibitors (SSRIs) are a class of anti-depressants that aim to regulate brain serotonin concentrations. Several small studies in psychiatric populations have administered SSRIs to impulsive--aggressive individuals, resulting in reduced impulsivity, anger, aggression and depression. However, no clinical trial has been undertaken in a criminal justice population. This protocol describes the design and implementation of the first systematic study of the potential benefits of SSRIs in impulsive---violent offenders who are at high risk of reoffending. METHODS AND ANALYSIS: A randomised, double-blinded, multicentre trial to test the clinical efficacy of an SSRI, sertraline hydrochloride, compared with placebo on recidivism and behavioural measures (including impulsivity, anger, aggression, depression and self-reported offending) over 12 months. 460 participants with histories of violence and screening positive for impulsivity are recruited at several local courts and correctional service offices in New South Wales, Australia. ETHICS AND DISSEMINATION: Results will be submitted for publication in a peer-reviewed journal. Possible implications of the effectiveness of this pharmacological intervention include economic benefits of reducing prison costs and societal benefits of improving safety. This study has received ethical approval from the University of New South Wales, Aboriginal Health & Medical Research Council, Corrective Services NSW and the NSW Justice Health and Forensic Mental Health Network. TRIAL REGISTRATION NUMBER: ACTRN12613000442707.

The Audio Recorded Cognitive Screen (ARCS): a flexible hybrid cognitive test instrument.

OBJECTIVE: To describe and characterise the Audio Recorded Cognitive Screen (ARCS), a novel instrument that uses an audio device to administer selected neuropsychological tests to unsupervised individuals who write their responses in a special booklet for later scoring. METHODS: The ARCS was administered to 733 individuals, comprising 550 from a normative community sample (mean age=59.14, range 18-84 years), 101 clinic patients and a separate validation sample of 82 community controls, who, together with the patients, underwent detailed neuropsychological assessments. These data were examined for the influence of demographic variables on ARCS performance, to establish normal performance and develop scoring routines, and to characterise the structure, reliability and validity of the instrument. RESULTS: Age, gender and education influenced ARCS performance. ARCS tests were generally reliable and correlated well with corresponding conventional neuropsychological tests. Factor analyses indicated that the ARCS measures executive functioning/attention, memory, language, verbal fluency and visuospatial functioning. The ARCS discriminated well between normal (n=82), impaired (n=33) and demented (n=25) individuals, and significantly better than did the Mini Mental State Examination (MMSE), including on a single, demographically adjusted, global QuickARCS score obtainable in about 3 min of the clinician's time. Receiver Operating Characteristic analyses confirmed the superiority of the ARCS over MMSE as a screen for mild dementia (AUC 0.98, 99% CI 0.95 to 1.00) or cognitive impairment (AUC 0.90, 99% CI 0.83 to 0.97). CONCLUSIONS: The ARCS has good validity and reliability, has a sound normative base and measures functioning in multiple cognitive domains while imposing minimal time demands upon the clinician.