Forensic mental health: envisioning a more empirical future.

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.

Two-state model of energy dissipation at metal surfaces.

The rates and pathways of chemical reactions at metal surfaces can be strongly influenced by energy dissipation due to the nonadiabatic excitation of metallic conduction electrons. The introduction of frictional forces to account for this dissipation has been quite successful in situations for which the nonadiabatic coupling is weak. However, in cases where nonadiabatic coupling is strong, such as when electron transfer occurs, the friction model is likely to break down. Ryabinkin and Izmaylov have proposed 2-state and 3-state alternatives to the friction model for introducing electronic dissipation in molecular dynamics simulations. Here, we examine their 2-state model using some simple examples of atom-surface scattering. We find that, with the addition of decoherence, the 2-state model can produce quite promising results.

Impaired striatal glutamate/GABA regulation in violent offenders with antisocial personality disorder and psychopathy.

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.

Neural correlates of aggression in personality disorders from the perspective of DSM-5 maladaptive traits: a systematic review.

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published in 2013, includes an alternative model of personality disorders (AMPD) focusing on a maladaptive trait model utilized to diagnose several personality disorders. Borderline personality disorder (BPD) and antisocial personality disorder (ASPD) are two conditions categorized by AMPD that exhibit high rates of violence and aggression. Several of the traits outlined in the AMPD, including hostility, impulsivity, risk-taking, and callousness, have been previously linked to aggression in BPD and ASPD. However, to the best of our knowledge, there has never been a synthesis of neuroimaging studies that have investigated links between these traits and aggression in BPD and ASPD. To overcome this gap, we conducted a systematic review under the PRISMA framework to locate neuroimaging articles published since the release of AMPD linking trait anger/hostility, impulsivity, risk-taking, and callousness to aggression in BPD and ASPD. Key findings included the following: i) anger/hostility, associated with alterations in the interplay between prefrontal and subcortical regions (primarily the amygdala), may be a common factor explaining aggressive reactions to response to interpersonal threat or provocation; ii) alterations of fronto-temporal-limbic regions and serotonergic and endocannabinoid signaling systems may link impulsivity to aggression in BPD and ASPD; iii) weaker cortico-striatal connectivity could relate to greater risk taking and greater proclivity for violence. Insufficient evidence from neuroimaging articles was discerned to describe a relationship between callousness and aggression. Overall, results of this review reveal a relative paucity of neuroimaging studies examining AMPD traits relevant to aggression in BPD and ASPD. In addition to encouraging further investigation of neuroimaging markers of AMPD traits linked to aggression, we recommend multi-methodological designs, including the incorporation of other biomarkers, such as hormones and indices of physiological arousal, to fully expand our understanding of aggression in BPD and ASPD.

Delays in transferring patients from prisons to secure psychiatric hospitals: An international systematic review.

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.

Knowledge and attitudes about conduct disorder of professionals working with young people: The influence of occupation and direct and indirect experience.

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.

Legal and human rights issues in the use of electronic monitoring (using GPS 'tracking' technology) in forensic mental health settings in the UK.

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.

Oxytocin normalizes the implicit processing of fearful faces in psychopathy: a randomized crossover study using fMRI.

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.

Psychopathy in women: insights from neuroscience and ways forward for research.

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.

Excited State Intramolecular Proton Transfer with Nuclear-Electronic Orbital Ehrenfest Dynamics.

The recent development of the Ehrenfest dynamics approach in the nuclear-electronic orbital (NEO) framework provides a promising way to simulate coupled nuclear-electronic dynamics. Our previous study showed that the NEO-Ehrenfest approach with a semiclassical traveling proton basis method yields accurate predictions of molecular vibrational frequencies. In this work, we provide a more thorough analysis of the semiclassical traveling proton basis method to elucidate its validity and convergence behavior. We also conduct NEO-Ehrenfest dynamics simulations to study an excited state intramolecular proton transfer process. These simulations reveal that nuclear quantum effects influence the predictions of proton transfer reaction rates and kinetic isotope effects due to the intrinsic delocalized nature of the quantum nuclear wave function. This work illustrates the importance of nuclear quantum effects in coupled nuclear-electronic dynamical processes and shows that the NEO-Ehrenfest approach can be a powerful tool for providing insights and predictions for these processes.

Impaired processing of threat in psychopathy: A systematic review and meta-analysis of factorial data in male offender populations.

BACKGROUND: Psychopathy is a personality disorder characterised by two underlying factors. Factor 1 (affective and interpersonal deficits) captures affective deficits, whilst Factor 2 (antisocial and impulsive/disorganised behaviours) captures life course persistent antisocial behaviours. Impaired processing of threat has been proposed as an aetiologically salient factor in the development of psychopathy, but the relationship of this impairment to the factorial structure of the disorder in adult male offenders is unclear. OBJECTIVES: To investigate whether threat processing deficits are characteristic of psychopathy as a unitary construct or whether such deficits are specifically linked to higher scores on individual factors. DATA SOURCES: A systematic review of the literature was conducted by searching PubMed, Web of Science and PsycINFO. METHODS: Studies were included if they (1) reported physiological measures of threat response as the primary outcome measure (2) indexed psychopathy using a well-validated clinician rated instrument such as the PCL-R (3) investigated male offenders between 18 and 60 years of age (4) reported threat processing analyses using both Factor 1 and Factor 2 scores (5) provided sufficient data to calculate effect sizes and (6) were published in English-language peer-reviewed journals. We identified twelve studies with data on 1112 participants for the meta-analysis of the relationship with Factor 1 scores, and nine studies with data on 801 participants for the meta-analysis of the relationship with Factor 2 scores. We conducted the meta-analyses to calculate correlations using random-effects models. RESULTS: PCL-R/SV Factor 1 scores were significantly and negatively related to threat processing indices (r = -0.22, (95%CI [-0.28, -.017]). Neither PCL-R/SV Factor 2 scores (r = -0.005, 95%CI [-0.10, 0.09]), nor PCL-R total score (r = -0.05, (95%CI [-0.15, -0.04]) were related to threat processing indices. No significant heterogeneity was detected for the Factor score results. CONCLUSIONS: The meta-analyses of the distinct psychopathy factors suggest that the threat processing deficits observed in male offenders with psychopathy are significantly associated with higher scores on Factor 1. A similar relationship does not exist with Factor 2 scores. Our findings highlight the importance of investigating the potentially discrete relationships between aetiological variables and the two factor constructs in the disorder.

Mental health services in the Philippines.

National information on mental health services in the Philippines indicates that there are substantial gaps and inconsistencies in the delivery of mental healthcare. The recently enacted Mental Health Act legislation provides a platform for the delivery of comprehensive and integrated mental health services. However, there remain many challenges in the provision of accessible and affordable mental healthcare.

Mental health legislation in the Philippines: Philippine Mental Health Act.

The first mental health act legislation in the history of the Philippines has been officially signed into law and was enacted as the Republic Act no. 11036 on 21 June 2018. It provides a rights-based mental health bill and a comprehensive framework for the implementation of optimal mental healthcare in the Philippines. We review the principles and provisions of the Mental Health Act of 2017 and the implications for mental healthcare in the Philippines.

Follow-up study of 6.5 years of admissions to a UK female medium secure forensic psychiatry unit.

Aims and methodWe aimed to examine clinical and risk outcomes at follow-up, and reoffending and readmission rates, for a sample of 50 admissions to a female medium secure unit (MSU). Demographic, clinical risk assessment (HCR-20 and HoNOS-Secure) and quality of life data were collected using validated measures for all admissions to a female MSU ward in London, UK, between April 2008 and November 2014. RESULTS: All clinical and risk assessment scale scores had improved at follow-up. Quality of life compared favourably to community samples and was good for physical, social and environmental factors and acceptable for psychological health. Twenty-six per cent had at least one readmission, while 17.5% reoffended in the period studied. A longer duration of admission and use of restrictions on discharge was associated with reduced reoffending, but not readmission.Clinical implicationsAdmission is associated with improvement on clinical risk assessment at follow-up. Longer hospital admissions and use of restrictions on discharge may be necessary to prevent reoffending in this group.Declaration of interestNone.

The effect of intranasal oxytocin on neural response to facial emotions in healthy adults as measured by functional MRI: A systematic review.

Abnormalities in responses to human facial emotions are associated with a range of psychiatric disorders. Addressing these abnormalities may therefore have significant clinical applications. Previous meta-analyses have demonstrated effects of the neuropeptide oxytocin on behavioural response to facial emotions, and effects on brain, as measured by functional MRI. Evidence suggests that these effects may be mediated by sex and the role of eye gaze. However, the specific effect of oxytocin on brain response to facial emotions in healthy adults has not been systematically analysed. To address this question, this further systematic review was conducted. Twenty-two studies met our inclusion criteria. In men, oxytocin consistently attenuated brain activity in response to negative emotional faces, particularly fear, compared with placebo, while in women, oxytocin enhanced activity. Brain regions consistently involved included the amygdala, fusiform gyrus and anterior cingulate cortex. In some studies, oxytocin increased fixation changes towards the eyes with enhanced amygdala and/or fusiform gyrus activation. By enhancing understanding of emotion processing in healthy subjects, these pharmacoimaging studies provide a theoretical basis for studying deficits in clinical populations. However, progress to date has been limited by low statistical power, methodological heterogeneity, and a lack of multimodal studies.

Erratum: Role of Tensorial Electronic Friction in Energy Transfer at Metal Surfaces [Phys. Rev. Lett. 116, 217601 (2016)].

This corrects the article DOI: 10.1103/PhysRevLett.116.217601.