Change in Severity of Mental Disorder of Remand Prisoners: An Observational Group-Based Trajectory Study.

BACKGROUND: Mental disorder is common among prisoners; however, little is known about how illness severity changes during incarceration, and especially to what extent there are different trajectories of change. AIMS: Our aims were to investigate trajectories of illness severity among male and female inmates with serious mental disorders, and to investigate whether clinical or demographic variables are associated with different trajectories. METHODS: We carried out a retrospective cohort study of newly remanded inmates who had three or more serial measures of illness severity as measured by psychiatrists using the Clinical Global Impression-Corrections (CGI-C), and used group-based trajectory modelling to identify trajectories. We investigated whether clinical and demographic variables were associated with different groups. RESULTS: We found an overall reduction in the severity of illness (mean change in CGI-C score -0.74, SD 1.5), with women showing greater improvement than men. We identified three distinct trajectories among men and three among women, all showing improvement in illness severity. Approximately 15% of the entire cohort had full resolution of symptoms, whereas the remainder showed partial improvement. Women, younger inmates, and those with substance use disorders were more likely to have full resolution of symptoms. CONCLUSIONS: Although most prisoners showed improvement, and a small proportion had full resolution of symptoms, a significant number continued to have moderately severe symptoms. There is a need for comprehensive treatment within the detention centre, but also a need for transfer to hospital for those with severe symptoms as improvement within the correctional setting tends to be modest.

PRN usage before and after discharge from a forensic inpatient unit: A series example of patients with intellectual disabilities.

Adults living with intellectual and developmental disabilities are often prescribed psychotropic medication on an "as needed" basis (PRN) in response to behavioural challenges. In the present study we conducted a retrospective analysis of medication administration records in the 6-months preceding and following discharge of 11 adults with intellectual and developmental disabilities to community settings from forensic inpatient units within a mental health hospital. We found a significant reduction in the frequency of PRN usage after discharge. We propose potential reasons for the difference in PRN administration across settings and make suggestions for future research.

Homicide associated with psychotic illness: What global temporal trends tell us about the association between mental illness and violence.

Available evidence suggests that persons with serious forms of mental illness are 4-10 times more likely to commit homicide as compared to non-affected members of the general population. The relationship between homicide and psychotic illness has now been subject to longitudinal investigation in six different populations across eight studies covering time periods over the last six decades. With the exception of one study, these investigations demonstrate that homicide associated with psychotic illness appears relatively stable through time and, in most populations, is not related to factors that contribute to the rise and fall of total population homicide (TPH) rates. This suggests that illness and treatment factors are of most importance if we are to reduce the prevalence of this tragic illness complication.

A comparison of men and women referred to provincial correctional mental health services in Ontario, Canada.

BACKGROUND: Women comprise around 15% of admissions to provincial correctional institutions in Canada. Women in custody are known to have a high prevalence of mental health concerns, but little is known about how those referred to mental health services compare with referred men at a similar stage of imprisonment. AIMS: Our aim was to describe and compare clinical, social and demographic characteristics of a complete cohort of custodially remanded men and women who were referred to mental health services while under custodial remand in two correctional institutions. METHODS: We carried out retrospective analysis of data obtained from 4040 men and 1734 provincially detained women referred to mental health services in two correctional centres holding mainly pre-trial prisoners and serving a large mixed urban-rural catchment area in Toronto, Canada over a nearly five-year period. Men and women were first screened using the Brief Jail Mental Health Screen. Those who screened positive were assessed using the Jail Screening Assessment Tool the Brief Psychopathology Rating Scale-Expanded (BPRS-E) and the Clinical Global Impression-Corrections (CGI-C). RESULTS: There were many similarities between men and women, but also some important differences. Women were more socioeconomically disadvantaged than men. More women than men reported having children, yet fewer reported having any form of employment or social supports, although men were more likely to report unstable housing. In addition, women were significantly more likely to have mood and anxiety problems and to be self-harming, but did not differ from men in current psychotic symptoms. We also found differences in patterns of substance use, with a higher proportion of women using heroin and methamphetamines but fewer women having accessed addiction services. CONCLUSIONS: Our findings have implications for clinicians and service planners. They underscore the value of systematic screening for identifying need. More specifically, they suggest need for increased availability of addiction services for women as well as ensuring support for those women who have dependent-age children. Improvement in supports for entry into employment is particularly needed for women, while men are particularly likely to need access to stable housing.

Patterns and Predictors of Reincarceration among Prisoners with Serious Mental Illness: A Cohort Study: Modèles et prédicteurs de réincarcération chez les prisonniers souffrant de maladie mentale grave : Une étude de cohorte.

BACKGROUND: A small proportion of people who have serious mental illness and rapid and frequent incarcerations account for a disproportionate amount of overall service use and cost. It is important to describe such individuals, so that services can respond more effectively. METHODS: We investigated a cohort of 4,704 incarcerated men and women who were discharged from a correctional mental health service and followed for a median of 535 days. We investigated social, clinical, demographic, and offense characteristics as predictors of return to the service using Cox survival analyses. Secondly, we characterized individuals as high-frequency service users as those who had 3 or more incarcerations during a 1-year period and investigated their characteristics. RESULTS: We found that a higher rate of return to custody was associated with schizophrenia spectrum/bipolar affective disorder (BPAD), personality disorder traits, crack cocaine and methamphetamine use, and unstable housing. Charges of theft/robbery and breach of probation were also positively associated, and sex assault was negatively associated with return to custody. Within a 1-year time period, we found 7.2% of individuals were high-frequency service users, which accounted for 19.5% of all reincarcerations. CONCLUSION: Identification of the characteristics of those with mental illness in custody, especially those who have high-frequency returns to custody, may provide opportunity to target resources more effectively. The primary targets of intervention would be to treat those with schizophrenia/BPAD and substance use problems, particularly those using stimulants, and addressing homelessness. This could reduce the problem of repeated criminalization of the mentally ill and reduce the overall incarceration rate.

Change in the Relationship Between Drinking Alcohol and Risk of Violence Among Adolescents and Young Adults: A Nationally Representative Longitudinal Study.

AIMS: To quantify the relationship between alcohol and violence with increasing age. METHODS: Data were from The National Longitudinal Study of Adolescent to Adult Health (ADD Health) of 20,386 people representative of the US population. Mean age at the first wave of interviews was 16.2 years, with subsequent interviews mean of 1, 6.3 and 12.9 years later. We used random-effects models and predictive marginal effects of the association between varying quantities of alcohol consumption and violence while controlling for possible confounders. RESULTS: Violence was reported by 19.1% of participants at wave I but just 2.1% at wave IV. The random-effects model showed that consuming 1-4 drinks on each occasion was associated with a modest increase in risk of violence in both males (odds ratio (OR) 1.36, 95% CI 1.13-1.63) and females (OR 1.33, 95% CI 1.03-1.72). For consumption of five or more drinks on each occasion, the risk remained similar for females (OR 1.40 (0.99-1.97)) but increased considerably for males (OR 2.41 (1.96-2.95)). Predictive marginal effects models confirmed that violence rates decreased with age. CONCLUSIONS: Alcohol is most strongly linked to violence among adolescents, so programmes for primary prevention of alcohol-related violence are best targeted towards this age group, particularly males who engage in heavy episodic drinking.

Management of COVID-19 Response in a Secure Forensic Mental Health Setting: Réponse à la gestion de la COVID-19 dans un établissement sécurisé de santé mentale et de psychiatrie légale.

OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic presents major challenges to places of detention, including secure forensic hospitals. International guidance presents a range of approaches to assist in decreasing the risk of COVID-19 outbreaks as well as responses to manage outbreaks of infection should they occur. METHODS: We conducted a literature search on pandemic or outbreak management in forensic mental health settings, including gray literature sources, from 2000 to April 2020. We describe the evolution of a COVID-19 outbreak in our own facility, and the design, and staffing of a forensic isolation unit. RESULTS: We found a range of useful guidance but no published experience of implementing these approaches. We experienced outbreaks of COVID-19 on two secure forensic units with 13 patients and 10 staff becoming positive. One patient died. The outbreaks lasted for 41 days on each unit from declaration to resolution. We describe the approaches taken to reduction of infection risk, social distancing and changes to the care delivery model. CONCLUSIONS: Forensic secure settings present major challenges as some proposals for pandemic management such as decarceration or early release are not possible, and facilities may present challenges to achieve sustained social distancing. Assertive testing, cohorting, and isolation units are appropriate responses to these challenges.

Assessment of need for inpatient treatment for mental disorder among female prisoners: a cross-sectional study of provincially detained women in Ontario.

BACKGROUND: International studies show a consistent finding of women in prisons as having a high prevalence of mental disorder. Most will be treated within the prison however the most severely ill require transfer to a hospital facility. The primary aim of our study was to survey the total provincial female prison population in Ontario, Canada, to determine the proportion that require treatment in a psychiatric hospital, and the security level required. The secondary aim was to investigate the validity and psychometric properties of DUNDRUM-1 and DUNDRUM-2 in making these assessments. METHODS: We carried out a cross-sectional study of all remand and sentenced female inmates detained in all 16 provincial jails that hold women in Ontario. The severity of mental health need was categorised by mental health staff on a five-point scale. Two forensic psychiatrists then examined all medical files of prisoners that had been categorised in the highest two categories and a random sample of nearly a quarter of those in the third category. An overall opinion was then made as to whether admission was required, and whether a high intensity bed was needed, and files were rated using DUNDRUM-1 and DUNDRUM-2. RESULTS: There were 643 female inmates in provincial prisons in Ontario. We estimated that approximately 43 (6.7%) required admission to a hospital facility, of which 21.6 [prorated] (3.4%) required a high intensity bed such as a psychiatric intensive care bed within a secure hospital. The DUNDRUM-1 and -2 tools showed good internal validity. Total scores on both DUNDRUM-1 and DUNDRUM-2 were significantly different between those assessed as needing admission and those who did not, and distinguished the level of security required. CONCLUSION: This is the first study to determine level of need for prison to hospital transfers in Canada and can be used to inform service capacity planning. We also found that the DUNDRUM toolkit is useful in determining the threshold and priorities for hospital transfer of female prisoners.

Assisted death for prisoners and forensic patients: complexity and controversy illustrated by four recent cases.

Medical assistance in dying (MAiD) (which includes euthanasia and assisted suicide) is available in an increasing number of countries. In Belgium, The Netherlands and Switzerland (and was due to be implemented in Canada from 2024) eligibility includes mental suffering in the absence of any physical disorder. There are particular ethical and legal issues when considering MAiD for those involuntarily detained in prisons and hospitals. We describe four recent cases that illustrate these complexities, and highlight issues of equivalence of healthcare and self-determination against concerns about the criteria for determining eligibility of those with non-terminal conditions as well as the objections raised by victims and families and the demands for justice.

Contributors to Physician Burnout and Well-Being in Forensic Psychiatrists in Canada.

The experience of burnout in forensic psychiatrists has not been well studied, with most studies focusing on the experiences of forensic nurses, the impact of vicarious trauma and compassion fatigue in forensic mental health professionals, and the risk of posttraumatic stress disorder related to workplace exposures. This study reports on a national survey (34% response rate) conducted with forensic psychiatrists across Canada to understand the rate of, and contributors to, burnout and professional fulfillment. Just over half of the physician respondents reported experiencing burnout, which is in line with other recent surveys in Canada that have indicated elevated levels of burnout since the onset of the pandemic. The highest rates were found among early-career psychiatrists and those whose values did not align with their workplace. Intellectual stimulation, the interface with the legal system, and flexibility in one's job were all strongly linked with professional fulfillment. The goal of this survey was not only to identify rates and variables affecting burnout and wellness in this population but also to expand the dialogue on potential interventions at institutional and systems levels that can reduce burnout, promote professional fulfillment, and enhance recruitment and retention in the field of forensic psychiatry.

COVID-19 Vaccine Hesitancy and Personality Traits; Results from a Large National Cross-Sectional Survey in Qatar.

Attitudes to vaccination arise from a complex interplay of personal and environmental factors. This has been true for the COVID-19 vaccination attitudes too and understanding personal factors would help design immunisation strategies that help in infectious disease control. The five-factor model of personality has been established as a valid construct in exploring individual attitudes and traits. This institutional review board approved study explores the relationship between these five domains of personality and attitudes to COVID-19 vaccination in Qatar which has a migrant majority population. A cross-sectional survey was conducted in Qatar using an online survey link containing validated tools to measure vaccine hesitancy and personality traits. People from diverse ethnic and sociodemographic backgrounds, amounting to 5340 individuals, completed the self-report survey. After controlling for social and demographic variables, individuals scoring significantly higher on Conscientiousness were more likely to refuse the COVID-19 vaccination, while those scoring significantly lower on Openness to experience and Neuroticism were also more likely to refuse COVID-19 vaccination. Both groups of individuals scoring significantly higher and lower on Conscientiousness and Neuroticism, respectively, were more likely to trust their own research than trust endorsement of the COVID-19 vaccine from their doctor or healthcare organisation. The study highlights the highly complex and sometimes contradictory relationship between vaccine hesitancy and personality traits and makes a case for understanding this relationship better in order to inform successful immunisation strategies.

Potassium Binding Interactions with Aliphatic Amino Acids: Thermodynamic and Entropic Effects Analyzed via a Guided Ion Beam and Computational Study.

Noncovalent interactions between alkali metals and amino acids are critical for many biological processes, especially for proper function of protein ion channels; however, many precise binding affinities between alkali metals and amino acids still need to be measured. This study addresses this need by using threshold collision-induced dissociation with a guided ion beam tandem mass spectrometer to measure binding affinities between potassium cations and the aliphatic amino acids: Gly, Ala, hAla, Val, Leu, and Ile. These measurements are supplemented by theoretical calculations and include commentary on effects of enthalpy, entropy, and structural preference. Notably, all levels of theory indicate that the lowest-lying isomers at 298 K have K+ binding to the carbonyl oxygen in either a monodentate ([CO]) or bidentate ([CO,OH]) fashion, isomers that are linked in a double-well potential. This complicates the analysis of the data, although does not greatly influence the final results. Analysis of the resulting cross sections includes accounting for multiple ion-molecule collisions, internal energy of reactant ions, and unimolecular decay rates. The resulting experimental bond dissociation energies generally increase as the polarizability of the amino acid increases, results that agree well with quantum chemical calculations done at the B3LYP, B3P86, and MP2(full) levels of theory, with B3LYP-GD3BJ predicting systematically larger values.

The Relationship Between the Big Five Personality Factors, Anger-hostility, and Alcohol and Violence in Men and Women: A Nationally Representative Cohort of 15,701 Young Adults.

Alcohol consumption is known to have a disinhibiting effect and is associated with a higher likelihood of aggressive behavior, especially among men. People with certain personality traits maybe more likely to behave aggressively when intoxicated, and there may also be variation by gender. We aimed to investigate whether the reason why men and women with certain personality traits are more likely to engage in violence may be because of their alcohol use.The Big Five personality traits and anger-hostility, alcohol consumption, and violence were measured by questionnaire in 15,701 nationally representative participants in the United States. We tested the extent to which alcohol mediates the relationship between personality factors and violence in men and women.We found that agreeableness was inversely associated with violence in both genders. Alcohol mediated approximately 11% of the effect in males, but there was no evidence of an effect in females. Anger-hostility was associated with violence in both sexes, but alcohol mediated the effect only in males. We also found that Extraversion was associated with violence and alcohol use in males and females. Alcohol accounted for 15% of the effect of extraversion on violence in males and 29% in females.The mechanism by which personality traits relate to violence may be different in men and women. Agreeableness and anger-hostility underpin the relationship between alcohol and violence in men, but not in women. Reducing alcohol consumption in men with disagreeable and angry/hostile traits would have a small but significant effect in reducing violence, whereas in women, reducing alcohol consumption among the extraverted, would have a greater effect.

Efficacy of mood stabilisers in the treatment of impulsive or repetitive aggression: systematic review and meta-analysis.

BACKGROUND: Individuals with repetitive or impulsive aggression in the absence of other disorders may be diagnosed with intermittent explosive disorder according to DSM-IV, but no such diagnostic category exists in ICD-10. Mood stabilisers are often used off-license for the treatment of aggression associated with a variety of psychiatric conditions, but their efficacy in these and in idiopathic aggression is not known. AIMS: To summarise and evaluate the evidence for the efficacy of mood stabilisers (anticonvulsants/lithium) in the treatment of impulsive or repetitive aggression in adults. METHOD: A meta-analysis of randomised controlled trials that compared a mood stabiliser with placebo in adults without intellectual disability, organic brain disorder or psychotic illness, identified as exhibiting repetitive or impulsive aggression. RESULTS: Ten eligible trials (489 participants) were identified A pooled analysis showed an overall significant reduction in the frequency/severity of aggressive behaviour (standardised mean difference (SMD) = -1.02, 95% CI -1.54 to -0.50), although heterogeneity was high (I(2) = 84.7%). When analysed by drug type, significant effects were found in the pooled analysis of three phenytoin trials (SMD = -1.34, 95% CI -2.16 to -0.52), one lithium trial (SMD = -0.81, 95% CI -1.35 to -0.28), and two oxcarbazepine/carbamazepine trials (SMD = -1.20, 95% CI -1.83 to -0.56). However, when the results of only those studies that had a low risk of bias were pooled (347 participants), there was no significant reduction in aggression (SMD = -0.28, 95% CI -0.73 to 0.17, I(2) = 71.4%). CONCLUSIONS: There is evidence that mood stabilisers as a group are significantly better than placebo in reducing aggressive behaviour, but not all mood stabilisers appear to share this effect. There is evidence of efficacy for carbamazepine/oxcarbazepine, phenytoin and lithium. Many studies, however, were at risk of bias and so further randomised controlled trials are recommended.

Suicide in high security hospital patients.

PURPOSE: People with mental disorder and people who are violent are separately recognised as being at high risk of suicide. People detained in high security hospitals are recognised for their violence to others, but perhaps less so for their suicide potential. We aimed to investigate suicide rates among such patients during and after their high security hospital residency, and to establish risk factors for suicide. METHODS: We extracted data from the Special Hospitals' Case Register on each person resident at any time between 1 January 1972 and 31 December 2000. Suicide rates were calculated for the whole period. We compared rates to the general population using standardised mortality ratios (SMRs). We used poisson regression to estimate the effects of gender, legal category of detention, offending history and length of admission on the suicide rate. RESULTS: Of the 5,955 individuals, 218 completed suicide. The suicide rate was nearly 7 times higher among resident men (SMR 662, 95% CI 478-845) and over 40 times higher in resident women (SMR 4,012, 95% CI 2,526-5,498) than in the general population; it was 23 times higher (SMR 2,325, 95% CI 1,901-2,751) and 45 times higher (SMR 4,486, 95% CI 2,727-6,245) among post-discharge men and women, respectively. The suicide rate was significantly higher among women than men inside high security but not after discharge. CONCLUSIONS: The suicide rate among high security hospital patients was significantly higher than in the general population. Women were especially at risk while resident, whereas for men, the risk was higher after discharge.

COVID-19 vaccine hesitancy and attitudes in Qatar: A national cross-sectional survey of a migrant-majority population.

BACKGROUND: Vaccine hesitancy is a global threat undermining control of preventable infections. Emerging evidence suggests that hesitancy to COVID-19 vaccination varies globally. Qatar has a unique population with around 90% of the population being economic migrants, and the degree and determinants of hesitancy are not known. METHODS: This study was carried out to evaluate the degree of vaccine hesitancy and its socio-demographic and attitudinal determinants across a representative sample. A national cross-sectional study using validated hesitancy measurement tool was carried out from October 15, 2020, to November 15, 2020. A total of 7821 adults completed the survey. Relevant socio-demographic data along with attitudes and beliefs around COVID-19 vaccination were collected from the respondents. RESULTS: 20.2% of the respondents stated they would not take the vaccine and 19.8% reported being unsure about taking the prospective COVID-19 vaccine. Citizens and females were more likely to be vaccine hesitators than immigrants and males, respectively. Concerns around the safety of COVID-19 vaccine and its longer-term side effects were the main concerns cited. Personal research around COVID-19 and vaccine were by far the most preferred methods that would increase confidence in accepting the vaccine across all demographic groups. CONCLUSIONS: This study reports an overall vaccine hesitancy of 20% toward the COVID-19 vaccine and the influence of social media on attitudes toward vaccination which is in keeping with emerging evidence. This finding comes at a time that is close to the start of mass immunization and reports from a migrant-majority population highlighting important socio-demographic determinants around vaccine hesitancy.

A Systematic Review of Reviews of Correctional Mental Health Services Using the STAIR Framework.

BACKGROUND: Rising demand for correctional mental health services (CMHS) in recent decades has been a global phenomenon. Despite increasing research, there are major gaps in understanding the best models for CMHS and how to measure their effectiveness, particularly studies that consider the overall care pathways and effectiveness of service responses. The STAIR (Screening, Triage, Assessment, Intervention, and Re-integration) model is an evidence-based framework that defines and measures CMHS as a clinical pathway with a series of measurable, and linked functions. METHOD: We conducted a systematic review of the reviews of CMHS elements employing PRISMA guidelines, organized according to STAIR pillars. We assessed the quality of included studies using the AMSTAR-2 criteria. Narrative reviews were read and results synthesized. RESULTS: We included 26 review articles of which 12 were systematic, metaanalyses, and 14 narrative reviews. Two systematic reviews and seven narrative reviews addressed screening and triage with strong evidence to support specific screening and triage systems. There was no evidence for standardised assessment approaches. Eight systematic reviews and seven narrative reviews addressed interventions providing some evidence to support specific psychosocial interventions. Three systematic reviews and six narrative reviews addressed reintegration themes finding relatively weak evidence to support reintegration methods, with interventions often being jurisdictionally specific and lacking generalizability. CONCLUSIONS: The STAIR framework is a useful way to organize the extant literature. More research is needed on interventions, assessment systems, care pathway evaluations, and reintegration models.