Developing a coordinated response to chemsex across health, justice and social care settings: expert consensus statement.

SUMMARY: Chemsex occurs primarily among gay, bisexual and other men who have sex with men (GBMSM), and there is evidence of a subgroup of users who carry out chemsex-related criminal offences and experience harm. Challenges with chemsex can present to various settings; there are concerns that harm is increasing, including at interfaces between health, social care and criminal justice systems. The UK response to date has lacked a coordinated approach. An expert reference group was convened to share chemsex knowledge, articulate priorities for research and pathway development, and foster collaborative working between agencies. It made three key recommendations: develop and increase training and awareness across all services; implement a coordinated research programme with the development of a common data-set and assessment tool to fully characterise population-level needs; develop a professional network to share information, provide professional support and act as a knowledge hub. There was support for a unified multi-agency strategy incorporating the priorities identified as overarching principles.

Why choose BJPsych Bulletin?

BJPsych Bulletin was first established as the Bulletin of the Royal College of Psychiatrists in 1977. Since then, it has extended its influence within the field, and it is now the go-to journal for practical clinical considerations in psychiatry, and mental health more widely. It stands together with the wider family of RCPsych journals - BJPsych, BJPsych Advances, BJPsych Open and BJPsych International - and offers a number of distinct advantages for readers and authors. I commend it to you.

Protecting and promoting editorial independence.

We argue that editorial independence, through robust practice of publication ethics and research integrity, promotes good science and prevents bad science. We elucidate the concept of research integrity, and then discuss the dimensions of editorial independence. Best practice guidelines exist, but compliance with these guidelines varies. Therefore, we make recommendations for protecting and strengthening editorial independence.

Variations in services and intervention pathways for traumatic stress in Welsh prisons: A national survey.

Both Post-Traumatic Stress Disorder and Complex Post-Traumatic Stress Disorder are prevalent in prison settings. Both often go undetected and untreated, while prisoners who already suffered previous trauma may be re-traumatised upon imprisonment. The current study aimed to conduct a national survey of all Welsh prisons to gather information about existing services and treatments for traumatic stress. The survey identified variation within Welsh prisons with regard to NICE-recommended evidence-based therapies. It is therefore recommended that there needs to be development of a pathway of Post-Traumatic Stress Disorder and Complex Post-Traumatic Stress Disorder in the prison system which should be achieved through a consensus process of both frontline staff and experts in the field.

A realist evaluation of an enhanced court-based liaison and diversion service for defendants with neurodevelopmental disorders.

BACKGROUND: In England, court-based mental health liaison and diversion (L&D) services work across courts and police stations to support those with severe mental illness and other vulnerabilities. However, the evidence around how such services support those with neurodevelopmental disorders (NDs) is limited. AIMS: This study aimed to evaluate, through the lens of court and clinical staff, the introduction of a L&D service for defendants with NDs, designed to complement the existing L&D service. METHODS: A realist evaluation was undertaken involving multiple agencies based within an inner-city Magistrates' Court in London, England. We developed a logic model based on the initial programme theory focusing on component parts of the new enhanced service, specifically training, screening, signposting and interventions. We conducted semi-structured interviews with the court staff, judiciary and clinicians from the L&D service. RESULTS: The L&D service for defendants with NDs was successful in identifying and supporting the needs of those defendants. Benefits of this service included knowledge sharing, awareness raising and promoting good practice such as making reasonable adjustments. However, there were challenges for the court practitioners and clinicians in finding and accessing local specialist community services. CONCLUSION: A L&D service developed for defendants with NDs is feasible and beneficial to staff and clinicians who worked in the court setting leading to good practice being in place for the defendants. Going forward, a local care pathway would need to be agreed between commissioners and stakeholders including the judiciary to ensure timely and equitable access to local services by both defendants and practitioners working across diversion services for individuals with NDs.

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.

Mental health intervention research in Latin American correctional settings: A scoping review.

BACKGROUND: The Latin American prison population has grown faster than anywhere else globally over the past two decades, reaching a total of 1.7 million people at any given time. However, research on mental health prevention and treatment interventions in Latin American prisons remains scarce. AIMS: This study aimed to systematically review and synthesize research on prison mental health interventions conducted in the region. METHODS: We used a two-stage scoping review design guided by the JBI Manual for Evidence Synthesis. Searches took place in December 2021 in nine databases using descriptors and synonyms. First, all prison mental health research in Latin America was retained. Secondly, using title and abstract screening, all research possibly related to interventions was retained for full text evaluation. Studies reporting interventions were assessed by country, language, institution, population, intervention type, intervention focus and outcomes. RESULTS: N = 34 studies were included in this review. These were 13 case reports, seven expert consensus papers and 14 quantitative studies (four randomized controlled trials, nine cohort studies, one quasi-experimental study). Fourteen interventions were targeted at promoting prosocial behavior, seven studies each aimed to improve mental health and to treat substance use disorders. Six studies involved the treatment of sexual offending behavior, and 3 focused on reducing criminal recidivism. Psychoeducation (n = 12) and motivational interviewing (n = 5) were the most frequent intervention types studied. Promising data from trials showed that anger management, depression, substance use and reoffending could be successfully addressed through interventions. CONCLUSIONS: Implementation and effectiveness research of mental health interventions in Latin American prisons is scarce. Addressing mental health, substance use and prosocial behavior outcomes should be considered in future research. There is a particular dearth of controlled trials describing quantifiable outcomes.

A systematic review of the co-occurrence of self-harm and aggression: Is dual harm a unique behavioural construct?

Introduction: Dual harm is the co-occurrence of self-harm and aggression during an individual's lifetime. It is unclear whether sufficient evidence exists for dual harm as a unique clinical entity. This systematic review aimed to examine whether there are psychological factors that are uniquely associated with dual harm when compared to those who have engaged in sole harm (self-harm alone, aggression alone) and no harmful behaviours. Our secondary aim was to conduct a critical appraisal of the literature. Methods: The review searched PsycINFO, PubMed, CINAHL, and EThOS on September 27, 2022, resulting in 31 eligible papers that represented 15,094 individuals. An adapted version of the Agency for Healthcare Research and Quality was used to assess risk of bias and a narrative synthesis was conducted. Results: The included studies assessed differences in mental health problems, personality, and emotion related factors between the different behavioural groups. We found weak evidence that dual harm is an independent construct with unique psychological characteristics. Rather, our review suggests that dual harm results from the interaction of psychological risk factors that are associated with self-harm and aggression. Discussion: The critical appraisal identified numerous limitations within the dual harm literature. Clinical implications and recommendations for future research are provided. Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=197323, identifier CRD42020197323.

Randomised controlled trial of the short-term effects of osmotic-release oral system methylphenidate on symptoms and behavioural outcomes in young male prisoners with attention deficit hyperactivity disorder: CIAO-II study.

BACKGROUND: Research has shown that 20-30% of prisoners meet the diagnostic criteria for attention-deficit hyperactivity disorder (ADHD). Methylphenidate reduces ADHD symptoms, but effects in prisoners are uncertain because of comorbid mental health and substance use disorders. AIMS: To estimate the efficacy of an osmotic-release oral system methylphenidate (OROS-methylphenidate) in reducing ADHD symptoms in young adult prisoners with ADHD. METHOD: We conducted an 8-week parallel-arm, double-blind, randomised placebo-controlled trial of OROS-methylphenidate versus placebo in male prisoners (aged 16-25 years) meeting the DSM-5 criteria for ADHD. Primary outcome was ADHD symptoms at 8 weeks, using the investigator-rated Connors Adult ADHD Rating Scale (CAARS-O). Thirteen secondary outcomes were measured, including emotional dysregulation, mind wandering, violent attitudes, mental health symptoms, and prison officer and educational staff ratings of behaviour and aggression. RESULTS: In the OROS-methylphenidate arm, mean CAARS-O score at 8 weeks was estimated to be reduced by 0.57 points relative to the placebo arm (95% CI -2.41 to 3.56), and non-significant. The responder rate, defined as a 20% reduction in CAARS-O score, was 48.3% for the OROS-methylphenidate arm and 47.9% for the placebo arm. No statistically significant trial arm differences were detected for any of the secondary outcomes. Mean final titrated dose was 53.8 mg in the OROS-methylphenidate arm. CONCLUSIONS: ADHD symptoms did not respond to OROS-methylphenidate in young adult prisoners. The findings do not support routine treatment with OROS-methylphenidate in this population. Further research is needed to evaluate effects of higher average dosing and adherence to treatment, multi-modal treatments and preventative interventions in the community.

Defendants with intellectual disability and autism spectrum conditions: the perspective of clinicians working across three jurisdictions.

The treatment of vulnerable defendants by criminal justice systems or correctional systems varies within and between countries. The purpose of this paper is to examine three legal jurisdictions - New South Wales in Australia; Norway; England and Wales - to understand the extent of variation in practice within the court systems for defendants with intellectual disabilities (ID) and/or autism spectrum conditions (ASC). Two of the jurisdictions had a process for screening in place, either in police custody or at court, but this was not universally implemented across each jurisdiction. All three jurisdictions had a process for supporting vulnerable defendants through the legal system. Across the three jurisdictions, there was variation in disposal options from a mandatory care setting to hospital treatment to a custodial sentence for serious offences. This variation requires further international exploration to ensure the rights of defendants with ID or ASC are understood and safeguarded.

The inter-connections between self-harm and aggressive behaviours: A general network analysis study of dual harm.

Dual harm is the co-occurrence of self-harm and aggression during an individual's lifetime. This behaviour is especially prevalent within criminal justice and forensic settings. The forms of aggression that should be included in the definition of dual harm have not yet been established. This study aimed to use network analysis to inform an evidence-based definition of dual harm by assessing the relationship between self-harm and different forms of aggressive behaviour in young people (N = 3,579). We used data from the Avon Longitudinal Study of Parents and Children (ALSPAC). Results revealed low correlations between the variables, leading to sparse network models with weak connections. We found that when separated into their distinct forms, aggressive acts and self-harm are only weakly correlated. Our work provides preliminary evidence to assist in understanding and managing dual harm within clinical and forensic settings and informs recommendations for future research.

Severe mental illness, common mental disorders, and neurodevelopmental conditions amongst 9088 lower court attendees in London, UK.

BACKGROUND: Court Mental Health Liaison and Diversion Services (CMHLDS) have developed in some countries as a response to the over-representation of mental illness and other vulnerabilities amongst defendants presenting to criminal justice (or correctional) systems. This study examined the characteristics and rates of mental disorder of 9088 defendants referred to CMHLDS. METHOD: The study analysed service level data, obtained from the National Health Service's mental health data set, to examine characteristics relating to gender, ethnicity and comorbidity of common mental and neurodevelopmental disorders at five CMHLDS across London between September 2015 and April 2017. RESULTS: The sample included 7186 males (79.1%) and 1719 females (18.9%), the gender of 183 (2%) were not recorded. Of those referred, 6616 (72.8%) presented with an identifiable mental disorder and 503 (5.5%) with a neurodevelopmental disorder (NDD). Significantly higher rates of schizophrenia were reported amongst Black defendants (n = 681; 37.2%) and Asian defendants (n = 315; 29%), while higher rates of depression were found amongst White defendants (n = 1007; 22.1%). Substance misuse was reported amongst 2813 defendants (31%), and alcohol misuse amongst 2111 (23.2%), with significantly high rates of substance and alcohol misuse amongst defendants presenting with schizophrenia or personality disorder. CONCLUSIONS: This is one of the largest studies to examine mental health needs and vulnerabilities amongst defendants presenting to CMHLDS. It will enable an improved understanding of the required service designs and resources required to manage the healthcare pathways for people attending CMHLDS.

The all-Wales forensic adolescent consultation and treatment service (FACTS): A 5-year referral cohort study.

BACKGROUND: FACTS is a Wales-wide mental health service for 10-17-year-olds with needs beyond the remit of mainstream child and adolescent mental health services (CAMHS). As a purely consultation-liaison service, it differs from other UK services in the field. AIMS: To describe a complete cohort of referrals to FACTS 2013-2017 with service exit by June 2018. METHODS: Clinical, social and offending data were extracted from FACTS records. RESULTS: 80 young people completed a FACTS episode, averaging nearly a year (309 days; range 13-859 days). Mostly boys (65, 81%) of mean age 15.4 years (range 9-18), two-thirds (n = 53) had three or more referral reasons, one invariably being threatened/actual harm to others; only half were criminal-justice involved. Half (41, 51%) were committing sexually harmful acts. Half were self-harming (41, 51%). All but seven had had at least one adverse childhood experience (ACE), nearly half (35, 44%) four or more. Nevertheless, post-traumatic stress disorder (PTSD) was rarely diagnosed (7, 9%); just over one-quarter (23, 29%) had no diagnosis at all. Correspondence analyses endorsed two distinct Attention deficit hyperactivity disorder groups, distinguished by presence/absence of evidenced brain damage or dysfunction. Suicide-related behaviours clustered with the other diagnoses, flashbacks and psychotic symptoms with no diagnosis. Change in home circumstances during a FACTS episode was slight. CONCLUSIONS: The complexity of presenting problems and service involvement evidences need for FACTS. The extent of persistently harmful sexual behaviours is a novel finding, suggesting need for more expert input for this at other service levels. Rarity of PTSD diagnoses was surprising given the extent of ACEs. This raises concerns that services focus on disorder signs rather than the child's inner life. Given the extent of problems, minimal change may be a positive outcome - especially when remaining in the community. Further development of this service should include explicit case-by-case goals and indicative outcome markers.