What next for adolescent forensic mental health research?

BACKGROUND: A small proportion of every nation's young people become sufficiently antisocial to come into contact with the criminal justice system. Many also have disorders of mental health or emotional well-being. Although countries vary in designating age of criminal responsibility, all must provide services for offenders, perhaps as young as 10, both to help them and safeguard their peers and the wider public. AIM: The aim of this article is to map the range of research required to support the development of satisfactory services for young mentally disordered offenders and identify knowledge gaps from a practitioner's perspective. METHODS: Using a public health prevention framework, we identified the main streams of research pertinent to young, mentally disordered offenders and sought examples of each to consider the extent to which they have been used to inform service development in England. FINDINGS: As in most countries, service development seems first driven by unusual, newsworthy cases. Overall, however, current English provision follows sound primary, secondary, and tertiary prevention principles with parallel tiers of service, including public health initiatives. Primary prevention and more specific treatments are likely to be informed by research findings, but service structure tends to emerge from a wider review base, including criminal justice, social and educational practitioner reviews, and also politics. Thus, services and populations of service users may change in advance of research evidence. Substantial reduction in numbers of young offenders in prison in England, for example, is clearly good in principle, but the intensity of need in the residual group is posing new challenges to which there are, yet, few answers. CONCLUSIONS: Although the last 15 years of coordinated service development in England has been broadly theoretically based, it has not been systematically assessed to establish what works best for whom. New problems emerging, such as new drugs of misuse, and new opportunities, such as technology for supporting and monitoring, require model studies. More research focusing on correlates of success is essential.

Three-Year Longitudinal Follow-up of the Psychiatry Early Experience Program (PEEP): Gaining and Sustaining Positive Attitudes Towards Psychiatry in Students at a UK Medical School.

OBJECTIVE: The Psychiatry Early Experience Programme (PEEP) is a novel enrichment activity at Kings College London medical school. Throughout their five-year degree, students shadow trainee psychiatry doctors. The study aimed to evaluate whether more regular early exposure affects attitudes towards psychiatry. METHODS: Forty first-year medical students joined PEEP and completed a baseline survey, including questions on demographics, current top three choices of medical specialty and the 30-item Attitudes Towards Psychiatry questionnaire (ATP-30). Participants completed annual follow up surveys, incorporating free-text questions about what students had learned and whether their views about psychiatry had changed. RESULTS: Over three years there was a sustained improvement in mean ATP-30 scores (8.27 points higher at three years than at baseline [95% CI 2.86-13.7, T=3.2, p=0.005]). There was no significant difference between baseline specialty choice and specialty choice at three-year follow-up. At three years there was a 55% response rate. There was no significant association between non-responders at three years and baseline ATP-30, specialty choice or demographic factors. Thematic analysis of qualitative data suggested that PEEP challenged preconceptions towards psychiatry and highlighted its relevance in medicine. CONCLUSIONS: The results offer some support that exposure to clinical psychiatry through longitudinal shadowing experiences can sustain positive attitudes. Areas for development include using a control group and following-up participants to the point when they specialize. It remains unclear whether it is most effective to select participants based on established commitment to psychiatry or to try to influence students who are still undecided.

An update on: meta-analysis of medical and non-medicaltreatments of the prodromal phase of psychotic illness in at risk mental states.

INTRODUCTION: There are now many existing studies which assess the treatments available for 'at risk mental states', as patients who are believed to be in the prodromal phase of psychotic illness are referred to. However, concerns regarding side effects of possible treatments remain. We here conduct a meta-analysis of the studies available up to July 2016. The aim of this study is to decide what would be the best treatment for 'at high risk patients'. RESULTS: 18 studies were selected for inclusion; 12 showed significance, 5 did not and one tended towards significance. Both antipsychotic medication and psychological intervention show mixed results with cognitive behavioral therapy and olanzapine/amisulpride coming out on top. Omega 3 poly-unsaturated acid also shows promising and consistent results. DISCUSSION: Treatments appear promising but a balance needs to be kept between adverse events and effectiveness of preventing psychosis. CONCLUSION: It is necessary to search further for treatments in order to identify effective treatments with fewer adverse side-effects in this phase of psychotic illness.

The Use of Psychotropic Drug Therapy in Borderline Personality Disorder: a Case Report.

It is estimated that around 75% of patients with Borderline Personality Disorder (BPD) are prescribed psychotropic medication during their treatment course, although this is not recommended as first line therapy. In the UK, there are no guidelines to advise which drug treatments to use in BPD, however, numerous, but mostly small scale studies, show evidence that different medications target specific core symptoms. We report a case of a 25 year old woman with BPD, who has received treatment with five different psychotropic medications. We go on to assess not only the efficacy of these treatments in this individual case, but also whether the use of these treatments is in line with best evidence according to currently available research.

Views from GP and Psychiatric trainees about getting experience in each other's specialty during training: A way to develop a shared culture?

The need to deliver holistic medical care that addresses both physical and mental health requirements has never been more important. The UK medical training system has been designed to provide all medical graduates with a broad experience of different medical specialities and psychiatry prior to entering specialist training. Furthermore there is a distinct crossover between Psychiatric and General Practice training, with programmes providing trainees with the opportunity to work alongside each other in the care of mental health patients. The video presentation will explain the UK medical training system in more detail, before going on to explore how the organisation of training may foster a shared culture among different specialities and how it could form a model for improving parity of esteem of medical and physical health care. In addition it will discuss the strengths and weaknesses of this system from a trainee perspective and will conclude with comments from eminent Psychiatrists whom have special interests in medical training and developingparity of mental and physical health care.

The incidence of Parkinson's disease in a Bedford Community "Adult Working Age" Mental Health Team and its relationship with the use of atypical antipsychotics: an audit and description of current practice.

Parkinson's disease (PD) is a common neurodegenerative condition of aging, however it is only seen infrequently in an Adult 'Working Age' Community Mental Health Team. When it presents, it presents in a number of different situations, but, since antipsychotics may often cause extrapyramidal side effects, there is often the concern that iatrogenic parkinsonism may occur. Here we describe a number of different patients presenting in a CMHT who have been assessed and investigated for Parkinson's disease. In many of these medication for Parkinson's disease was started. Often the patients need to stay on an atypical antipsychotic because of the mental health symptoms which they present. We assess present practice in the team, and make recommendations.

An audit to compare patient factors (age, sex, social background & associated physical diagnoses) in people with refractory depression in a Bedfordshire Community Mental Health Team (BCMHT) being augmented with (A) mirtazepine, (B) atypical antipsychotics or (C) both.

In recent years, there has been particular interest in the use of augmentation as a strategy for the treatment of refractory depression. The purpose of this audit was to define patient factors among people receiving augmentation therapy with either mirtazepine or atypical antipsychotics. We searched an anonymised database of patients and identified those with receiving augmentation with mirtazepine (group A), atypical antipsychotics (group B) or both (group C). The audit reveals some interesting differences in patient factors between the three groups. Knowledge about such differences is useful in practical terms because it allows doctors in the BCMHT to target therapy for different patients towards their specific needs. However, the audit cannot explain the underlying reasons for these differences.

An audit to compare the efficacy of treatment (as indicated by discharge rates and reduction in suicidality) among patients with refractory depression in a Bedfordshire Community Mental Health Team receiving augmentation therapy with either mirtazepine or atypical antipsychotics.

In recent years, there has been particular interest in the use of augmentation. Potential augmentation regimes include the addition of atypical antipsychotics (e.g. risperidone/olanzapine) or other antidepressants (e.g. mirtazepine). The purpose of this audit was to compare patient outcomes between groups receiving different augmentation strategies. Overall we found that augmentation with mirtazepine resulted in better outcomes in terms of both discharge rates and in terms of reduction in suicidality than augmentation with atypical antipsychotics.

Perspectives of GCSE students attending a psychiatry summer school in south London.

AIMS AND METHOD: This study evaluated a pilot psychiatry summer school for GCSE students in terms of participant experience, effects on attitudes to mental illness and perception of psychiatry as a career option. This was done using the Community Attitudes towards the Mentally Ill scale, career choice questionnaires and a discussion group following the week-long programme attended by 26 students. RESULTS: Students were significantly more likely to choose psychiatry after the summer school (P = 0.01). There were statistically significant changes in scores for social restrictiveness (P = 0.04) and community mental health ideology (P = 0.02). Qualitative analysis generated four themes: variation in expectations, limited prior knowledge, perception of the summer school itself and uniformly positive attitudes to psychiatry after the summer school. CLINICAL IMPLICATIONS: Targeting students at this early stage appears to be an underexplored positive intervention for improving both attitudes towards mental illness and recruitment to psychiatry.

An audit to identify factors affecting response to treatment among depressed patients who have documented suicidal ideation/attempts in a Bedfordshire Community Mental Health Team.

INTRODUCTION: in recent years there has been a general move towards treating depressed patients in the community if at all possible. One factor that may reduce the likelihood of discharge from secondary care is suicidality (Butler et al. 2010). The aim of this audit was to identify factors associated with continued suicidality among patients in a CMHT. SUBJECTS AND METHODS: we searched an anonymised database of patients and identified all those with previously documented suicidal thoughts or attempts. We also noted the presence of factors such as alcohol problems, drug problems, augmentation therapy and 'other risk' factors (e.g. financial problems or homelessness). We then looked at clinical notes to find out whether or not, according to the latest clinic letter, patients were still reporting suicidality. This facilitated comparison of the aforementioned factors between the group of patients in which suicidality was still present (group N) and the group of patients in which suicidality was no longer a feature (group Y). RESULTS: of the 56 patients with suicidal thoughts or attempts there were 44 in group N (79%) and 12 in group Y (21%). Overall, alcohol problems, drug problems and 'other' risk factors were proportionally more common among group Y than group N, although sometimes the difference was marginal. Conversely, the percentage of patients on augmentation therapy was greater in group N than group Y. When considering individual diagnostic categories the above trends generally stood for the F32 category, although not necessarily for the F33 category. DISCUSSION: the audit provides an insight into the sorts of factors that might influence outcomes among depressed patients. However, there are limitations to the audit such as small sample size and lack of a fixed follow-up period. CONCLUSIONS: Although the results are suggestive, it is difficult to make firm conclusions about patient outcomes on the basis of this data. The audit provides a useful starting point, especially in considering the treatment of patients within the BECMHT. However, further research on a wider scale is required before more general conclusions can be made about factors influencing response to treatment among depressed patients.

An audit to identify factors that are more commonly associated with depressed patients on augmentation therapy under the Befordshire East Community Mental Health Team (BECMHT).

BACKGROUND: whilst it is important that we treat patients with depression in primary care if possible there are many patients with depression who will need the more expert support provided in secondary care. AIMS AND METHODS: an Anonymised Database held by the Bedford East Community Mental Health Team was studied to assess what factors were related to the use of Augmentation Strategies to treat resistant depression. RESULTS: of the total 282 patients 109 (38.7%) were on augmentation therapy. In the F32 and F33 group just over a third of the patients (35.8% and 37.1%) were on augmentation therapy and in the F41.2 group over a half of patients (56.7%) were on augmentation therapy. DISCUSSION: There does seem to be a relationship between the number of risk factors a patient has and the likelihood that they are on augmentation. Particularly strong factors are another psychiatric diagnosis and 'other suicide risk factors'. CONCLUSION: generally the patients coming to secondary care with more of the specified risk factors are more likely to need augmentation.

Meta-analysis of medical and non-medical treatments of the prodromal phase of psychotic illness in at-risk mental states.

INTRODUCTION: there are now many existing studies which assess the treatments available for 'at risk mental states', as patients who are believed to be in the prodromal phase of psychotic illness are referred to. However, concerns regarding side effects of possible treatments remain. We here conduct a meta-analysis of the studies available up to October 2010. The aim of this study is to decide what would be the best treatment for 'at high risk patients'. RESULTS: all the available studies examining potential treatments during the prodromal phase of psychotic illness were collected. They all showed comparable efficacy, which reached statistical significance, excluding the one study using olanzapine, which in fact 'tended towards significance'. DISCUSSION: treatments appear promising but a balance needs to be kept between adverse events and effectiveness of preventing psychosis. CONCLUSION: it is necessary to search further for treatments in order to identify effective treatments with fewer adverse side effects in this phase of psychotic illness.