Modifiable risk factors for inpatient violence in psychiatric hospital: prospective study and prediction model.

BACKGROUND: Violence perpetrated by psychiatric inpatients is associated with modifiable factors. Current structured approaches to assess inpatient violence risk lack predictive validity and linkage to interventions. METHODS: Adult psychiatric inpatients on forensic and general wards in three psychiatric hospitals were recruited and followed up prospectively for 6 months. Information on modifiable (dynamic) risk factors were collected every 1-4 weeks, and baseline background factors. Data were transferred to a web-based monitoring system (FOxWeb) to calculate a total dynamic risk score. Outcomes were extracted from an incident-reporting system recording aggression and interpersonal violence. The association between total dynamic score and violent incidents was assessed by multilevel logistic regression and compared with dynamic score excluded. RESULTS: We recruited 89 patients and conducted 624 separate assessments (median 5/patient). Mean age was 39 (s.d. 12.5) years with 20% (n = 18) female. Common diagnoses were schizophrenia-spectrum disorders (70%, n = 62) and personality disorders (20%, n = 18). There were 93 violent incidents. Factors contributing to violence risk were a total dynamic score of ⩾1 (OR 3.39, 95% CI 1.25-9.20), 10-year increase in age (OR 0.67, 0.47-0.96), and female sex (OR 2.78, 1.04-7.40). Non-significant associations with schizophrenia-spectrum disorder were found (OR 0.50, 0.20-1.21). In a fixed-effect model using all covariates, AUC was 0.77 (0.72-0.82) and 0.75 (0.70-0.80) when the dynamic score was excluded. CONCLUSIONS: In predicting violence risk in individuals with psychiatric disorders, modifiable factors added little incremental value beyond static ones in a psychiatric inpatient setting. Future work should make a clear distinction between risk factors that assist in prediction and those linked to needs.

Development of the FORUM: a new patient and clinician reported outcome measure for forensic mental health services.

Forensic mental health services provide care to people in secure psychiatric hospitals and via specialised community teams. Such services are typically low volume and high cost, often highly restrictive and average duration of inpatient care prior to discharge is long. Measuring outcomes of care is important to safeguard patients and the public, monitor progress, inform treatment plans and assist in service evaluation and planning. We describe the development in England of a new outcome measure for forensic mental health services. Patient interviews and multistakeholder focus groups were held to elicit key concepts. Thematic analysis was used to develop an outcomes framework. Fifteen patients participated in the interviews and 48 stakeholders in the focus groups. Six domains were identified in thematic analysis: 'about me, my quality of life, my health, my safety and risk, my life skills and my progress'. Sixty-two stakeholders participated in the first round of the Delphi process, and 49 completed round two. Eight of the top fifteen outcomes were shared between patients/carers and professionals. Based on these results, a new outcome measure, the FORensic oUtcome Measure (FORUM), was developed including both a patient reported and clinician reported measure. Further assessment of the FORUM's use to track patients' progress over time, and facilitate shared decision-making and care planning, is required.

Psychiatric training in perinatal mental health across Europe.

Perinatal mental illness is associated with considerable maternal and infant morbidity and mortality. However, there are currently no specific guidelines on the standards and structure of postgraduate perinatal psychiatric training in Europe. We describe the characteristics of available and desired specialist perinatal psychiatry training from the perspective of European psychiatrists in training. An online survey was conducted among 34 national psychiatric trainee association representatives of the European Federation of Psychiatric Trainees (EFPT). Participants from the countries in which perinatal psychiatry training was available were invited to participate in in-depth follow-up interviews. Six countries out of 34 (18%) reported that specialist training in perinatal mental health was available (Finland, France, Germany, Ireland, Malta, and the UK). The nature of available training varied in duration, the supervision and assessment model employed, and the training scheme context. Of the 28 countries where specialist perinatal psychiatry training was unavailable, the majority of national representatives (22 countries, 76%) wanted specialist perinatal psychiatry training to be included in their national training curricula. There is a gap between the expected skills and the available training for psychiatrists to meet the mental healthcare needs of women in the perinatal period. Given the prevalence and impact of perinatal mental illness and the expressed desires of trainees themselves for specialist training, this finding should prompt urgent action.

Advancing research in adult secure mental health services in England.

Forensic mental health services in high income countries are typically high cost and low volume, providing care to people with mental illness, personality disorders, learning disability and autism deemed to pose a risk to others. Research into how forensic mental health services work as a whole system is limited. Such research is urgently needed to guide policy makers and ensure that services operate effectively.

Mental health services in the prisons of Bangladesh.

In this narrative review we consider what is known about mental health conditions in the prison system in Bangladesh and describe the current provision of mental health services for prisoners with mental health needs. We contextualise this within the literature on mental health conditions in correctional settings in the wider sub-continental region and low- and middle-income countries (LMICs) more broadly. We augment findings from the literature with information from unstructured interviews with local experts, and offer recommendations for research, policy and practice.

Ten outcome measures in forensic mental health: A survey of clinician views on comprehensiveness, ease of use and relevance.

BACKGROUND: Measurement of outcomes in forensic mental health services is essential to ensure that these services are delivering good quality care and treatment. Instruments for outcome measurement should cover all important domains, be easy to implement in a routine clinical context and facilitate transfer of relevant information between clinicians as the patient progresses along a recovery and rehabilitation pathway. AIMS: We sought the views of clinicians on 10 common instruments used as outcome measures in forensic mental health services, especially on their perceived comprehensiveness and ease of use. METHODS: An online survey was used to gather the views of clinicians from a range of professional backgrounds working in forensic mental health services in the United Kingdom. The selected instruments were identified from a previous systematic review of instruments for measuring outcomes in this context. Questions covered comprehensiveness, ease of use, patient involvement, relevance and use for progressing tracking and care planning. RESULTS: Complete responses were received from 229 individuals. The range of respondents either agreeing or strongly agreeing that individual instruments were comprehensive was 6-39%; easy to use 19%-69%; relevant 31%-78%; useful to measure progress 7-70%; and useful for care planning 33-81%. Respondents reported that, for each of the 10 instruments, full involvement of patients varied between 3% and 22%; partial involvement 12-45%, patients informed, but not involved 11%-28%; and patients not involved or informed 21%-64%. CONCLUSIONS: The Health of the Nation Outcome Scale Secure, the only instrument designed as an outcome measure, is not regarded by clinicians as useful in that respect and the majority of clinicians do not inform patients they are using it. Clinicians appear most familiar with the Historical Clinical Risk 20 (HCR-20), which some respondents considered potentially useful as a progress measure but with limited patient involvement. Most respondents did not think that the HCR-20 is comprehensive. There is a need for outcome measures that are comprehensive, easy to use and have adequate patient involvement in their development and rating.

Liaison and diversion services in South East London: Referral patterns over a 25-year period.

Criminal justice liaison and diversion services identify people with mental health needs and ensure they receive appropriate support. We describe a 25-year period of one such service that deals with a population of 864,540 in South East London that was set up in 1991. We used data from three time periods. A diagnosis of a mental illness was recorded in 70.0-80.3% of court liaison and diversion referrals. The proportion receiving a hospital order declined from 15.4% in 1991/1992 to 1.1% in 2015/2016; 54/199 (27.1%) of referrals to the police liaison and diversion service were detained in hospital. Although the service is designed to support any individual with a mental health issue, these results suggest that it has dealt mainly with people who have severe mental illness. Further research is required to understand how best to benefit a wider range of people with mental health issues who attend the lower (Magistrates') courts, and whether screening for mental disorders can be applied in liaison and diversion settings to aid the implementation of national policy. We also need to understand how disposal decisions are made, and which are most effective.

Psychiatry training in 42 European countries: A comparative analysis.

Psychiatry qualifications are automatically recognized among European Union (EU) countries despite differences in national training programs. A widening gap between the number of psychiatrists, their competencies and the growing burden of mental illnesses in Europe has renewed calls for international standardization of training. Comprehensive information about training programs is missing, which limits thorough comparisons and undermines development of an actionable strategy to improve and harmonize psychiatry training. This study describes and compares the existing postgraduate psychiatry programs in 42 countries in the European region. Representatives of national psychiatry associations completed a semi-structured, 58-item questionnaire. Training structure and working conditions of each country were compared with population needs calculated by the World Health Organization to determine the European mean and contrasted among pre-2004 and post-2004 EU members and countries with unrecognized qualifications. Differences were tested with nonparametric (Wilcoxon) and parametric (Anova) tests. Median training duration was 60 months, significantly shorter in countries with unrecognized qualifications (48 months, χ²16.5, p < 0.001). In 80% of the countries, placement in a non-psychiatric specialty such as neurology or internal medicine was mandatory. Only 17 countries (40%) stipulated a one-month rotation in substance abuse and 11 (26%) in old-age psychiatry. The overall deficit of training versus population need was 22% for substance abuse and 15% for old-age psychiatry. Salaries were significantly higher in pre-2004 EU members (χ²22.9, p < 0.001) with the highest in Switzerland (€5,000). Significant variations in curricula, training structure and salaries exist in Europe. Harmonization of training standards could offer significant benefits for improving mental healthcare.

Predicting self-harm in prisoners: Risk factors and a prognostic model in a cohort of 542 prison entrants.

BACKGROUND: Self-harm is common in prisoners. There is an association between self-harm in prisoners and subsequent suicide, both within prison and on release. The aim of this study is to develop and evaluate a prediction model to identify male prisoners at high risk of self-harm. METHODS: We developed an 11-item screening model, based on risk factors identified from the literature. This screen was administered to 542 prisoners within 7 days of arrival in two male prisons in England. Participants were followed up for 6 months to identify those who subsequently self-harmed in prison. Analysis was conducted using Cox proportional hazard regression. Discrimination and calibration were determined for the model. The model was subsequently optimized using multivariable analysis, weighting variables, and dropping poorly performing items. RESULTS: Seventeen (3.1%) of the participants self-harmed during follow up (median 53 days). The strongest risk factors were previous self-harm in prison (adjusted hazard ratio [aHR] = 9.3 [95% CI: 3.3-16.6]) and current suicidal ideation (aHR = 7.6 [2.1-27.4]). As a continuous score, a one-point increase in the suicide screen was significantly associated with self-harm (HR = 1.4, 1.1-1.7). At the prespecified cut off score of 5, the screening model was associated with an area under the curve (AUC) of 0.66 (0.53-0.79), with poor calibration. The optimized model saw two items dropped from the original screening tool, weighting of risk factors based on a multivariable model, and an AUC of 0.84 (0.76-0.92). CONCLUSIONS: Further work is necessary to clarify the association between risk factors and self-harm in prison. Despite good face validity, current screening tools for self-harm need validation in new prison samples.

Health Education and Activity - Lessening The Inequalities in mental health (HEA - LTI mental health).

Patients suffering from mental health illness have considerably more physical health disease burden than the rest of the population and are more likely to die 10 to 20 years younger compared with their peers. Diabetes, cardiovascular and respiratory disease have been recognised as contributing factors to premature death. Furthermore patients with severe mental illness undertake lower levels of physical activity. The aim of the project was therefore to address the inequalities in physical health that affect patients with mental health illness through designing and implementing a sustainable, transferable, patient-centred education and activity intervention. The objective of the project was to increase patient motivation to change behaviour as a result of physical health interventions by increasing patients' physical health understanding, motivation to change their physical health behaviour, motivation to do exercise and by reducing their anxiety. The method used was a prospective cohort study in four eighteen bed psychosis inpatient units. The units were across two large London hospitals in one Hospital Trust involving male and female inpatients with a range of mental health issues. The intervention was comprised of two components. The first component was a weekly 45 minute teaching group designed in collaboration with patients focusing on the key domains that affect the physical health of mental health patients. Four discussion domains (heart health, diabetes and weight, smoking and lung disease, cancer screening and substance misuse) were undertaken, with each cycle lasting four weeks. The second component was a weekly 45 minute exercise group ('normalisation activity') in collaboration with patients and the multidisciplinary team. The intervention was evaluated at the end of each cycle and four cycles in total took place. Weekly pre and post intervention measures were undertaken comprising of a self reported change in understanding, motivation to change physical health behaviours, confidence to change, anxiety and motivation to exercise. The result was a 26% improvement in self-reported understanding across the four domains following teaching. Furthermore patient anxiety reduced by on average 35%, self-reported motivation to change increased by 20%, motivation to do exercise by 26% and confidence to change by 16% as a result of the intervention. The authors conclude that a collaborative approach to education and activity between the Multidisciplinary Team (MDT) and service user results in sustained improvement in understanding of physical health, motivation to change behaviour and to do exercise. It also results in improved confidence and reduced anxiety.

Coaching for recovery: a quality improvement project in mental healthcare.

Approximately one in four adults in the UK will experience a mental health difficulty at some point in their life. This figure is approximately 400 million people worldwide.[1] Depression alone is currently estimated to cost the UK 1.7% of GDP and is one of the largest causes of ill health in the world.[2] For conditions like psychosis, evidence tells us that people have poorer quality of life outcomes, are more likely to die early, become obese, smoke, be unemployed, and have long term physical conditions than average.[3] People's social situation is also likely to be more complex, with housing needs, social isolation, stigma, and poverty.[4] All of these factors can make it hard for a person with a long-term mental health condition, or those supporting them, to hold onto a sense of hope that positive change is possible or that "recovery" towards a life that holds optimum meaning to them is achievable. An innovative "pop up" Recovery College model was co-produced, delivered, and evaluated by a team of people with lived experience of mental health difficulties, known as peer trainers. The Recovery College offered courses containing the best evidence-based knowledge about recovery in mental health, self-care and self-management. Each learning session included theory, personal testament from peer trainers, and volunteers and demonstrations of practical self-care skills and techniques. The courses were open to people experiencing mental health difficulties, their families, friends, and professionals. After the college course finished each student was offered up to three individual coaching sessions to help support putting the lessons learnt from the college into practice. The project aimed to test whether this innovative educational and coaching model could offer hope, knowledge and practical skills in self-management to support resilience and recovery. The project was underpinned by quality improvement methodologies to develop, deliver, and refine the model.

In the spotlight: healthcare inspections as an opportunity for trainee clinicians to be the leaders of today.

There have been repeated calls from all quarters of healthcare for more clinicians to be leaders. The risks of not accepting this responsibility have been demonstrated by harrowing reports into failed care in England. Ambiguity persists over what clinical leadership encompasses, how it can be developed and how to inspire clinicians to practise it. A supportive organisational culture, dedicated resources and national support are needed to foster leadership skills among trainee clinicians. Here we discuss a possible blueprint based on the recent reviews of English NHS Trusts with high mortality rates for future initiatives in empowering medical and nursing trainees to learn from leaders and practise leadership skills.