Patients with depression who self-refer for transcranial magnetic stimulation treatment: exploratory qualitative study.

Aims and methodAs part of a larger clinical trial concerning the use of transcranial magnetic stimulation (TMS) for treatment-resistant depression, the current study aimed to examine referral emails to describe the clinical characteristics of people who self-refer and explore the reasons for self-referral for TMS treatment. We used content analysis to explore these characteristics and thematic analysis to explore the reasons for self-referral. RESULTS: Of the 98 referrals, 57 (58%) were for women. Depressive disorder was the most commonly cited diagnosis, followed by bipolar affective disorder. Six themes emerged from the thematic analysis: treatment resistance, side-effects of other treatments, desperation for relief, proactively seeking information, long-term illness and illness getting worse.Clinical implicationsTMS has recently been recommended in the UK for routine use in clinical practice. Therefore, the number of people who self-refer for TMS treatment is likely to increase as its availability increases.Declaration of interestNone.

European Psychiatric Association (EPA) guidance on forensic psychiatry: Evidence based assessment and treatment of mentally disordered offenders.

Forensic psychiatry in Europe is a specialty primarily concerned with individuals who have either offended or present a risk of doing so, and who also suffer from a psychiatric condition. These mentally disordered offenders (MDOs) are often cared for in secure psychiatric environments or prisons. In this guidance paper we first present an overview of the field of forensic psychiatry from a European perspective. We then present a review of the literature summarising the evidence on the assessment and treatment of MDOs under the following headings: The forensic psychiatrist as expert witness, risk, treatment settings for mentally disordered offenders, and what works for MDOs. We undertook a rapid review of the literature with search terms related to: forensic psychiatry, review articles, randomised controlled trials and best practice. We searched the Medline, Embase, PsycINFO, and Cochrane library databases from 2000 onwards for adult groups only. We scrutinised publications for additional relevant literature, and searched the websites of relevant professional organisations for policies, statements or guidance of interest. We present the findings of the scientific literature as well as recommendations for best practice drawing additionally from the guidance documents identified. We found that the evidence base for forensic-psychiatric practice is weak though there is some evidence to suggest that psychiatric care produces better outcomes than criminal justice detention only. Practitioners need to follow general psychiatric guidance as well as that for offenders, adapted for the complex needs of this patient group, paying particular attention to long-term detention and ethical issues.

Patient characteristics and outcome measurement in a low secure forensic hospital.

BACKGROUND: Health services are increasingly required to measure outcomes after treatment, which can be reported to the funding body and may be scrutinised by the public. Extensive high-quality measurements are time consuming. Routinely collected clinical data might, if anonymised, provide good enough evidence of useful change consequent on service received. RESEARCH QUESTION: Do the Health of the Nation Scale and the 20-item Historical, Clinical, Risk structured professional judgement tool scores provide evidence of clinical and risk change among low security hospital patients at 6 and 12 months after admission? METHODS: One hundred and eight men were either resident on the unit on 1 January 2011 or new admissions to the census date of 31 May 2013. Their routinely collected data were added to an outcome register following each patient's Care Programme Approach clinical review meeting and analysed using repeated measures t-tests with Bonferroni corrections. RESULTS: Most of the men, mean age 34.3 years, were single (93%), White British (71%) and with a primary diagnosis of schizophrenia (62%). There were significant reductions in the 11-item Health of the Nation Scale (excluding the community living condition scale) scores between baseline and 6 months and between 6 and 12 months, but no change on its additional 7-item secure subscale. Individual effect sizes indicated that 39% of the men had better social function, although 18% had deteriorated at 6 months. There was little overall change in the 20-item Historical, Clinical, Risk; individual effect sizes indicated that 11 men (15%) were rated as being at lower risk level and 10 (14%) at higher after 6 months in the study. CONCLUSIONS/IMPLICATIONS FOR CLINICAL PRACTICE: Standard clinical measures are promising as indicators of change in low security hospital patients. Risk ratings may be conservative, but at this stage of a secure hospital admission, higher scores may be as likely to indicate progress in identifying and quantifying risks as apparent increase in risk. Copyright © 2017 John Wiley & Sons, Ltd.

Circles of Support and Accountability for Sex Offenders: A Systematic Review of Outcomes.

We conducted a systematic review of studies reporting on the effectiveness of Circles of Support and Accountability (Circles). Circles use volunteers to provide support for sex offenders living in the community. We searched 10 databases up to the end of 2013 and identified 3 relevant outcome studies. An additional 12 papers or reports were identified by searching reference lists, Google, and contacting key authors and Circles providers to obtain unpublished data. These 15 studies comprised one randomized controlled trial, three retrospective cohorts with matched controls, and 11 case series. The majority reported measures of recidivism, particularly reconviction. The 4 studies with controls generally reported that participation in Circles was associated with lower recidivism although there were few statistically significant differences. Few studies examined changes in risk or psychosocial outcomes. A number of methodological issues are discussed. Longer term, prospective follow-up studies with control groups are required to address these issues.

Circles of support and accountability: The characteristics of core members in England and Wales.

BACKGROUND: Circles of support and accountability, or Circles, use community volunteers to help reintegrate sex offenders at risk of reoffending in the community. AIMS: The aims of this study are to describe the first 275 male sex offenders ('core members') in England and Wales supported by a Circle and to compare those attending the five largest Circles. METHODS: As part of their monitoring activity, 10 Circles extracted data from case files, anonymised it and submitted it to Circles UK, the national oversight body. RESULTS: Circles have expanded rapidly with 165 (60%) of Circles commencing in the three years 2011-2013 compared with 110 in the nine years 2002-2010. Most core members were referred from the Probation Service (82%). Circles were provided to men with a range of predicted risks of reoffending - from low (26%) to very high (12%). There were some positive changes between the beginning and end of Circles, such as fewer men being unemployed and more living in their own chosen accommodation. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: Circles have been used to support the reintegration of a wide range of sex offenders. Given their rapid growth and flexibility, consistent recording standards are required across. These standards should be reviewed periodically to ensure all important fields of change are captured, including frequency of attendance, length per session and quality of engagement in the work. Copyright © 2016 John Wiley & Sons, Ltd.

High-Volume Repeaters of Self-Harm.

BACKGROUND: Repetition of self-harm is common and is strongly associated with suicide. Despite this, there is limited research on high-volume repetition. AIM: To investigate individuals with high-volume repeat self-harm attendances to the emergency department (ED), including their patterns of attendance and mortality. METHOD: Data from the Multicentre Study of Self-Harm in England were used. High-volume repetition was defined as ⩾15 attendances within 4 years. An attendance timeline was constructed for each high-volume repeater (HVR) and the different patterns of attendance were explored using an executive sorting task and hierarchical cluster analysis. RESULTS: A small proportion of self-harm patients are HVRs (0.6%) but they account for a large percentage of self-harm attendances (10%). In this study, the new methodological approach resulted in three types of attendance patterns. All of the HVRs had clusters of attendance and a greater proportion died from external causes compared with non-HVRs. CONCLUSION: The approach used in this study offers a new method for investigating this problem that could have both clinical and research benefits. The need for early intervention is highlighted by the large number of self-harm episodes per patient, the clustered nature of attendances, and the higher prevalence of death from external causes.

A Descriptive Study of Feelings of Arrested Escape (Entrapment) and Arrested Anger in People Presenting to an Emergency Department Following an Episode of Self-Harm.

BACKGROUND AND OBJECTIVES: To explore the role of elevated feelings of anger and desires to escape (fight/flight), which are experienced as inhibited, blocked, and arrested (i.e., arrested anger and arrested flight/escape leading to feelings of entrapment). This descriptive study developed measures of arrested anger and arrested flight and explored these in the context of a recent self-harm event in people presenting to a Hospital's Emergency Department (ED). METHODS: Fifty-eight individuals presenting to an ED following an act of self-harm were recruited. Participants completed newly developed measures of arrested flight, arrested anger and anger with self in regard to self-harm, and suicide intent and depression. RESULTS: Ninety-three percent of participants presented after self-poisoning. The majority (95%) reported having experienced high escape motivation that felt blocked (arrested flight) with 69% reporting feeling angry with someone but unable to express it (arrested anger). For many participants (53.7%), strong desires to escape from current situations and/or to express anger did not diminish immediately after the act. LIMITATIONS: As with many studies, a select group of participants agreed to take part and we did not keep records of how many refused. There are no other validated measures of arrested escape and arrested anger and so for this study, our short item-focused measures rely on face validity. CONCLUSION: Arrested defenses of fight and flight, and self-criticism are common in those who have self-harmed and may continue after acts of self-harm. Many participants revealed that talking about their experiences of escape motivation and blocked anger (using our measures) was helpful to them. PRACTICE POINTS: Feelings of entrapment and arrested anger are common in people who self-harmClinicians could benefit from increased awareness and measures of arrested flight and arrested angerDiscussing these concepts and experiences appears to be useful to people who have self-harmedFurther research is needed on how best to help people with such experiences.

Alcohol use and misuse, self-harm and subsequent mortality: an epidemiological and longitudinal study from the multicentre study of self-harm in England.

OBJECTIVES: Alcohol use and misuse are strongly associated with self-harm and increased risk of future self-harm and suicide. The UK general population prevalence of alcohol use, misuse and alcohol-attributable harm has been rising. We have investigated the prevalence of and trends in alcohol use and misuse in self-harm patients and their associations with repeat self-harm and subsequent death. METHODS: We used patient data from the Multicentre Study of Self-Harm in England for 2000-2009 and UK mortality data for patients presenting from 2000 to 2007 who were followed up to the end of 2009. RESULTS: Alcohol involvement in acts of self-harm (58.4%) and alcohol misuse (36.1%) were somewhat higher than found previously in self-harm patients. Alcohol involvement and misuse were most frequent in men, those aged 35-54 years and those from white ethnicities. The frequency of alcohol misuse increased between 2000 and 2009, especially in women. Repetition of self-harm was associated with alcohol involvement in self-harm and particularly with alcohol misuse. Risk of suicide was increased significantly in women misusing alcohol. CONCLUSIONS: Alcohol use and misuse in self-harm patients appears to have increased in recent years, particularly in women. The association of alcohol with greater risk of self-harm repetition and mortality highlights the need for clinicians to investigate alcohol use in self-harm patients. Ready availability of alcohol treatment staff in general hospitals could facilitate appropriate aftercare and the prevention of adverse outcomes.

The influence of admission characteristics on outcome: evidence from a medium secure forensic cohort.

OBJECTIVE: Outcomes for any mental health service will vary with the characteristics of those admitted as well as with the clinical provision of the service itself. This study aims to explore, for a medium secure forensic service in England, temporal changes in (1) characteristics of those admitted and (2) outcome after discharge and (3) to examine whether such changes are related. METHOD: Baseline characteristics and reconviction outcomes were derived from multiple data sources for 550 first admissions to a medium secure forensic unit for a 20-year period. Time to reconviction was examined using Kaplan-Meier analysis and Cox regression. RESULTS: Over time, severity of admissions increased, as did discharges to prison; discharges to non-secure hospitals reduced. Risk of reconviction increased by 3.9%-4.2% for each year of admission from 1983, which was explained by the increased admission of higher-risk patients. CONCLUSION: This medium secure service admitted patients with increasing levels of risk; reoffending rates reflect admission characteristics. Service funding decisions should take account of the characteristics of those admitted. SIGNIFICANT OUTCOMES: This study indicates that the profile of patients admitted over a 20-year period increased in severity. Over time, reconviction after discharge occurred earlier after release. This increase in reconviction was explained by the type of patient admitted. LIMITATIONS: Examination of a cohort from a single medium secure unit limits the generalizability of the findings. The study focuses on a criminological outcome measure (i.e. reconviction); other domains may be equally relevant (e.g. the relief of psychological distress). Examining an entire series of admissions introduces heterogeneity by, for example, considering the outcome of men and women together.

Patients with a history of arson admitted to medium security: characteristics on admission and follow-up postdischarge.

Patients who set fires are a perennial cause of concern with psychiatric services although perhaps rather neglected in the clinical research literature. The current study considered the characteristics on admission of 129 patients, 93 men and 36 women, with a known history of arson who had been admitted to a medium secure psychiatric hospital. The distinguishing characteristics of the sample were high numbers of patients with extensive criminal histories, most probably due to high levels of prison transfer and a higher occurrence of mental illness than psychopathic disorder. Aside from return to prison, most patients were discharged either to another psychiatric hospital or directly to the community. There was a high rate of re-conviction after discharge, mainly for minor offences, with about one in 10 of discharged patients committing arson. It was established, however, that not all incidents of arson led to a prosecution. It is concluded that there are weaknesses in the areas of both risk assessment and evidence-based treatment for arsonists.

A survey of how clinicians in forensic personality disorder services engage their service users in treatment.

Non-completion is a significant problem in treatments for personality disorder (PD), and is associated with poorer outcomes. Clinicians routinely attend to engagement issues with people diagnosed with PD and so we accessed their views about the techniques they used to facilitate treatment engagement with service users with PD. Twenty-three clinicians from a range of disciplines were asked how they defined treatment engagement, what they thought were the causes of treatment engagement problems in people with PD, and what techniques or strategies they used to enhance engagement of people with PD. Data were analysed using inductive thematic analysis. Staff working with people with PD have broad views on the factors that are implicated in treatment engagement for their client group. Consequently, the techniques they use to engage service users are wide-ranging, addressing issues to do with services, individuals, therapies and therapists. Given the limited published data thus far, the suggestions generated may be of value to other practitioners in improving service user engagement.

Long-term suicide risk in forensic psychiatric patients.

The objectives of this study was to describe the rate of suicide and other causes of death in first admissions to a (medium) secure forensic psychiatric facility. All 595 patients were followed up for a maximum of 20 years. Death certificates were obtained and Standardized Mortality Ratios (SMRs) were calculated. At the June 2003 census, 57 patients (9.6%) had died of whom 18 (3.0%) had committed suicide; if deaths categorized as open verdicts are included the number rises to 26 (4.4%). The SMR for death by suicide was higher for a Mental Health Act classification of Mental Illness (SMR = 3,553) compared to Psychopathic Disorder (SMR = 1,892). The risks of mortality in this population are high from any cause, particularly from suicide.

Long-term outcomes after discharge from medium secure care: a cause for concern.

BACKGROUND: There are few long-term follow-up studies of patients discharged from medium secure units in the UK, even though these units were introduced over 20 years ago. AIMS: To describe mortality, rates of reconviction at different time periods; violent behaviour (not leading to conviction), readmission and employment, after discharge from a medium secure unit. METHOD: Of 595 first admissions over a 20-year period, 550 discharged cases were followed-up. Multiple data sources were used. RESULTS: Fifty-seven (10%) patients had died, of whom 18 (32%) died by suicide, and the risk of death was six times greater than in the general population. Almost half (49%) of those discharged were reconvicted and almost two-fifths (38%) of patients were readmitted to secure care. CONCLUSIONS: Community psychiatric services need to be aware that those discharged from medium secure care are a highly vulnerable group requiring careful follow-up if excess mortality, high levels of psychiatric morbidity and further offending are to be prevented.

Penetration of etched enamel and dentin cavity surfaces by bonding agent/composite resin.

Mechanical and adhesive advantage of resin bonding agents depend upon the ability to penetrate microspaces created with acid-etchants and close adaptation to cavity surfaces. As a replicating material, these resins may reveal morphologic characteristics of the cavity surfaces not seen by direct scanning electron microscope (SEM) investigation. The purpose of this study was to describe, with the SEM, the resin replications of acid-etched cavity walls of Class V cavity preparations in the labial and lingual surfaces of extracted premolar teeth. Cavities were prepared in the gingival third of these surfaces in 26 freshly extracted human premolar teeth using fissure burs in water-cooled, high-speed handpieces. The cavosurface margins were bevelled. The preparations were washed in tap water, dried, etched for 20 seconds with 35% phosphoric acid, coated with light-cured bonding agent and filled with light-cured composite resin in two applications. The teeth were dissolved in acid and the cavity walls of the composite examined in the SEM. Features observed included: (a) Type II resin penetration of interrod regions, (b) resin penetration of the lamellae to the dentino-enamel junction (DEJ), (c) a 10-20 microns step in surface contour at the DEJ, with penetration of terminal tubule branches, (d) insular regions of deep dentin tubule penetration and (e) 100-300 microns deep, 10-30 microns incremental microlamellar penetrations into the enamel at the DEJ corresponding to enamel tufts.

Scanning microscopy of resin infiltration patterns in acid-etched incisor enamel.

Previous studies have described the surface morphologic characteristics of acid-etched enamel. The purpose of this investigation was to examine the patterns of resin infiltration into the etched enamel. Fourteen, human, incisor teeth, extracted because of advanced periodontal disease, were etched on the labial surfaces for 60 seconds with 37% phosphoric acid, washed in tap water, and then air-dried. A self-cured enamel resin was applied to the etched labial surface and supported with epoxy. The teeth were dissolved in formic acid. The resin remnants were cleaned in water, dried, mounted on specimen stubs, coated with sputtered gold, and examined in a Scanning electron microscope (SEM). Resin infiltration patterns were photographed in the SEM at a magnification of 400 in 0.125-mm2 areas of the incisal, middle, and gingival thirds of each labial surface. Resin infiltration patterns were scored according to the correspondence with the rod-core, rod-periphery, and irregular acid-etch patterns seen in enamel. The distribution of resin infiltration patterns was as follows: rod-core, 9.7%; rod-periphery, 40.5%; and irregular, 49.7%. The values were averaged over all the surface areas. Infiltration patterns into the etched enamel exhibited deep interperikymata resin penetration. Subsurface channeling of resin was responsible for the pattern seen in irregular etch and was the most common form of infiltration in the gingival region. Subsurface channeling may be related to the development of micropores observed in incipient carious lesions. Deep monomer penetration and channeling may be important factors in mechanical attachment.