Who is at risk? Adults with intellectual disability at risk of admission to mental health inpatient care.

BACKGROUND: NHS England's Transforming Care agenda aims to reduce the number of adults with intellectual disabilities and autistic adults in mental health hospitals. The aim was to understand the demographic and clinical characteristics of those most at risk of admission. METHOD: A cohort, retrospective study of adults using community intellectual disability services in the North West of England from 2018 to 2022 was undertaken. RESULTS: We compared 211 adults at imminent risk of admission to a mental health hospital and 249 at significant (but not imminent) risk on a validated risk stratification tool. Individuals at significant risk were more likely to have moderate intellectual disability. Individuals at imminent risk were more likely to have diagnoses of mild intellectual disability, autism, personality disorder, or psychosis. CONCLUSION: By furthering our understanding of the clinical characteristics of those most at risk of admission, the findings inform more appropriate targeting of resources.

Perspectives of service users and carers with lived experience of a diagnosis of personality disorder: A qualitative study.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Personality disorder is a serious mental health condition affecting up to 52% of psychiatric outpatients and 70% of inpatients and forensic patients. People with a diagnosis of personality disorder have higher morbidity and mortality than those without. Service users and carers reported a lack of training for staff in the management of individuals with a diagnosis of personality disorder, particularly with regard to self-harm and suicidal behaviours. Staff burnout creates barriers to compassionate person-centred care for individuals with a diagnosis of personality disorder as staff struggled to accommodate the nature of the presentation when under significant emotional, psychological and professional strain caused by understaffing and lack of support. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This paper adds new knowledge by informing services of ways to improve care provision from the perspectives of both carers and service users. A more holistic and less medicalised approach to the treatment of problems associated with a diagnosis of a personality disorder should be adopted, and personality disorder training introduced for all healthcare practitioners, to improve patient outcomes. ABSTRACT: INTRODUCTION: There is limited understanding of the experience of people with complex mental health (CMH) needs, including those with a diagnosis of personality disorder (PD) and carers of those individuals. Little is known about carers of those in inpatient forensic settings, yet it has been identified that they may have additional needs when compared to general carers. Research highlights that community carer support services were perceived as inadequate and out-of-area placements were described as putting an added strain on ability to support loved ones. Understanding PD within a population of people with CMH needs and how a diagnosis described as PD impacts on care and treatment experience is vital to providing high-quality care. AIM: To evaluate the care experience of service users and carers with lived experience of a diagnosis of PD and out-of-area placements. METHOD: Semi-structured interviews were conducted with six service users and four carers to explore the experiences and perspectives of people with a diagnosis of PD. Interviews were audio recorded and thematically analysed. RESULTS: Four interrelated themes were developed; Influence of a diagnosis of PD on Staff, Early and Appropriate Intervention, Recognition of the Individual and Training and Knowledge of people with a diagnosis of PD. DISCUSSION: Anti-stigma interventions for staff, research on care provision and structural changes to services including more evidence-based therapy for individuals with a diagnosis of PD may help reduce disparate treatment and improve prognosis for recovery. IMPLICATIONS FOR PRACTICE: This paper informs services of ways to improve care provision from the perspective of carers and service users. A more holistic and less medicalised approach to the treatment of problems associated with diagnoses of PD should be adopted, and PD training for all healthcare practitioners to improve patient outcomes.

Factors Influencing Emergency Department Staff Decision-Making for People Attending in Suicidal Crisis: A Systematic Review.

BACKGROUND: Emergency department (ED) staff are often the first point of contact for individuals in suicidal crisis. Despite this, there is no published research systematically examining the factors influencing decision-making for this patient group. METHODS: MedLine, CINAHL, PsycINFO, Web of Science and Cochrane Library databases were searched for three key concepts: (1) suicide, (2) accident and emergency department and (3) decision-making. Three reviewers screened titles, abstracts and full papers independently against the eligibility criteria. Data synthesis was achieved by extracting and analyzing study characteristics and findings. The Mixed Methods Appraisal Tool (MMAT) was used to assess the quality of included studies. RESULTS: Seventeen studies met the eligibility criteria and were included in this systematic review. Studies were published from 2004 to 2020 and were of good methodological quality. A number of patient (method of self-harm, age, gender), contextual (availability of services and staff) and staff-related factors (attitudes, training, knowledge) were reported to influence decision-making for patients in suicidal crisis presenting to EDs. CONCLUSION: Decision-making in the ED is complex and is influenced by patient, contextual and staff-related factors. These decisions can have an impact on the future care and clinical pathways of patients in suicidal crisis. Additional training is needed for ED staff specifically related to suicide prevention.

Socioeconomic Predictors of Crisis and Clinical Pathways Among People Contacting a Mental Health Crisis Line.

Objective: Crisis lines are the first mental health service contact point for many people, making them a vital community and public health intervention. Given the current and potential utility of crisis lines, better understanding the characteristics, socioeconomic factors and subsequent referral pathways of callers is critical to identifying targeted ways to improve such services. Study Design: The dataset captured calls to the Cheshire & Wirral Partnership NHS Foundation Trust (CWP) crisis line between August 2020 and August 2021. Calls were examined if self-harm, risk to self, or overdose were reported by the caller. Descriptive analyses were conducted to produce a clinical and demographic profile of the callers using the crisis line. Results: Call handlers were significantly more likely to call 999, hand over to a practitioner and less likely to provide advice and guidance if self-harm, risk to self or overdose was reported. Social issues were found to be significantly associated with all 3 outcomes: self-harm, risk to self and overdose. Conclusion: The current study provides the first exploratory analysis of the socioeconomic factors and resultant care pathways for those contacting a UK crisis line service. The findings have important implications for community early intervention efforts to reduce self-harm and suicidal behaviours.

Staff perspectives of emergency department pathways for people attending in suicidal crisis: A qualitative study.

WHAT IS KNOWN ON THE SUBJECT?: Emergency departments (ED) are key settings to support and manage suicidal crisis; thus, ED staff are often the first point of contact for people in suicidal crisis. Despite this, some ED staff receive little training and/or education on how to best support such patients. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE: Previous research focuses on one staffing role (e.g. triage nurses) whereas this paper includes staff working across the ED pathway. Administrative staff have often been excluded from research, despite representing a key part of the clinical pathway and being a person's initial contact with the ED. Overall findings demonstrate that staff experience a lack of confidence, training and burnout due to regularly supporting people in suicidal crisis. Staff also perceive there to be a negative ED culture, which often leads to poor attitudes towards suicidal crisis. The main challenges reported are an increase in working pressures, unavailability of resources and staff retention. Findings build upon previous research to highlight key challenges different staff face along the clinical pathway and the implications this can have on a patient's journey and follow-up care provided. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Findings are of particular importance and relevance to ED managers, and more broadly NHS England. Negative ED culture, poor staff attitudes and confidence can have a detrimental impact on both staff health and wellbeing, as well as a patient's journey throughout the ED, resulting in repeat presentations and absconding as appropriate support is not received. Policymakers need to consider staff burnout and lack of resources in mental health care strategies, and training programmes should be developed to improve culture and confidence among ED staff and managers to improve care for people attending EDs in suicidal crisis. ABSTRACT: INTRODUCTION: Emergency departments (EDs) are often the first point of contact for people in suicidal crisis. Yet, previous work has tended to focus on only one type of staffing role, failing to account for different staff perspectives along the clinical pathway. AIMS: To explore and synthesise the perspectives of ED administrative (i.e. receptionists), medical (triage nurses) and mental health staff (liaison psychiatrists) working with people presenting in suicidal crisis. METHOD: Qualitative study guided by thematic analysis of semi-structured interviews with 23 ED staff across six EDs in Cheshire and Merseyside, England. RESULTS: Findings demonstrate that staff experience a lack of confidence, training and burnout due to regularly supporting people in suicidal crisis. The main challenges reported are an increase in working pressures, unavailability of resources and staff retention. DISCUSSION: Staff felt unequipped to deal with suicide-related presentations. Organisational support is perceived to be lacking, with increased staffing pressures and poor service availability. This lack of support was linked to job dissatisfaction. IMPLICATIONS FOR PRACTICE: Findings are of particular relevance to individual EDs and NHS England. Addressing the challenges staff are reporting can have positive implications for staff wellbeing, as well as a patient's experience and journey throughout the ED.

Investigating the impact of undiagnosed anxiety and depression on health and social care costs and quality of life: cross-sectional study using household health survey data.

BACKGROUND: There is uncertainty around the costs and health impacts of undiagnosed mental health problems. AIMS: Using survey data, we aim to understand the costs and health-related quality-of-life decrements from undiagnosed anxiety/depression. METHOD: We analysed survey data from two waves of the North West Coast Household Health Survey, which included questions on disease, medications, and Patient Health Questionnaire 9 (PHQ-9) and Generalised Anxiety Disorder 7 (GAD-7) scores (depression and anxiety scales). People were judged as having undiagnosed anxiety/depression problems if they scored ≥5 on the PHQ-9 or GAD-7, and did not declare a mental health issue or antidepressant prescription. Linear regression for EuroQol 5-Dimension 3-Level (EQ-5D-3L) index scores, and Tweedie regression for health and social care costs, were used to estimate the impact of undiagnosed mental health problems, controlling for age, gender, deprivation and other health conditions. RESULTS: Around 26.5% of participants had undiagnosed anxiety/depression. The presence of undiagnosed anxiety/depression was associated with reduced EQ-5D-3L index scores (0.040 lower on average) and increased costs (£250 ($310) per year on average). Using a higher cut-off score of 10 on the PHQ-9 and GAD-7 for undiagnosed anxiety/depression had similar increased costs but a greater reduction in EQ-5D-3L index scores (0.076 on average), indicating a larger impact on health-related quality of life. CONCLUSIONS: Having undiagnosed anxiety or depression increases costs and reduces health-related quality of life. Reducing stigma and increasing access to cost-effective treatments will have population health benefits.

Predictors of self-harm and emergency department attendance for self-harm in deprived communities.

Emergency departments (EDs) are often the first point of contact for individuals following self-harm. The majority of previous research relies on hospital-based data, yet only a minority of individuals who self-harm in the community present to healthcare services. The study design is cross-sectional survey design. Data from the National Institute for Health Research Applied Research Collaboration North West Coast (NIHR ARC NWC) Household Health Survey, a community-based public health survey in North West England, was collected using stratified random sampling. Three thousand four hundred twelve people were recruited in 2018 from relatively disadvantaged areas. The sample included 1490 men and 1922 women aged 18 to 100 years (M = 49.37, SD = 18.91). Logistic regression analysis was employed to examine demographic, health and socioeconomic predictors of self-harm and ED attendance for self-harm. Age (18-24 years), lower financial status, depression, anxiety and physical and mental health co-morbidity was associated with significantly higher levels of self-harm. People aged 18-24 years, with physical and mental health co-morbidity and lower levels of social support had significantly higher levels of attending EDs for self-harm. Improving people's financial situations, social connectivity, mental and physical health may help to reduce individual risk for self-harm and strain on health services.

Longitudinal investigation of the presence of different trajectories and associated health and socio-economic determinants, for participants who report suicidal ideation within a community-based public health survey.

OBJECTIVE: Given the paucity of evidence-based research investigating different suicidal ideation profiles and trajectories, this project sought to investigate health and socio-economic factors associated with the presence of suicidal ideation and changes in ideation over time. DESIGN: Longitudinal cohort design, using logistic regression analysis. SETTING: A public health survey was administered at two timepoints in a community setting across the North West of England. In the 2015/2016 survey, participants were recruited from high (n=20) and low (n=8) deprivation neighbourhoods. In the 2018 survey, only the 20 high-deprivation neighbourhoods were included. PARTICIPANTS: 4287 people were recruited in 2015/2016 and 3361 were recruited in 2018. The 2018 sample was subdivided into those who responded only in 2018 (n=2494: replication sample) and those who responded at both timepoints (n=867: longitudinal sample). PRIMARY OUTCOME MEASURES: Suicide ideation was the dependent variable which was assessed using item 9 of the Patient Health Questionnaire instrument. RESULTS: The prevalence of suicidal ideation was 11% (n=454/4319) at 2015/2016 and 16% (n=546/3361) at 2018.Replication study results highlighted: persistent debilitation from physical ill health and/or medication side effects; demographic factors (ie, middle-aged, single or never married); and personal coping strategies (ie, smoking) as risk factors for suicidal ideation. A static/improved financial position and high levels of empathy were protective factors.Longitudinal study results confirmed three suicidal ideation trajectories: 'onset', 'remission' and 'persistence'. Similar findings to the replication study were evidenced for the onset and persistence trajectories. Persistent suicidal ideation was synonymous with higher levels of practical support which may correspond to the higher levels of debilitation and functional disability reported within this group. Remission was characterised by fewer debilitating factors and higher levels of self-agency. CONCLUSION: A greater appreciation of the heterogeneity of suicidal trajectories should lead to the implementation of broad clinical assessments and targeted interventions.

Causation, historiographic approaches and the investigation of serious adverse incidents in mental health settings.

To improve the safety of healthcare systems, it is necessary to understand harm-related events that occur in these systems. In mental health services, particular attention is paid to harm arising from the actions of patients against themselves or others. The primary intention of examining these adverse events is to inform changes to care provision so as to reduce the likelihood of the recurrence of such events. The predominant approach to investigating adverse incidents has relied on the cause-and-effect conceptualisation of past events. Whilst the merits of approaches which are reliant on cause-and-effect narratives have been questioned, alternatives models to explain adverse incidents in health settings have not been theoretically or empirically tested. This novel article (i) examines the notion of causation (and the related notion of omission) in the context of explaining adverse events in mental health settings, and (ii) draws on a long-established discipline devoted to the study of how the past is interpreted (namely historiography) to theoretically investigate the innovative application of two historiographical approaches (i.e. counterfactual analysis and historical materialism) to understanding adverse events in mental health settings.

A study of the implementation of patient safety policies in the NHS in England since 2000: what can we learn?

PURPOSE: Despite repeated policy initiatives, progress in improving patient safety in the National Health Service (NHS) in England over the past two decades has been slow. The NHS Patient Safety Strategy (NHS England and NHS Improvement, 2019), which is being implemented currently, aims to address this problem. The purpose of this study is to identify learning from the implementation of past patient safety policies and thereby suggest means of supporting the NHS in delivering the current policy initiative successfully. DESIGN/METHODOLOGY/APPROACH: The authors identified key health policies in the domain of patient safety, published since 2000, by searching the United Kingdom (UK) government website. Discussion papers from the research literature concerning these policies were collated and reviewed. The authors then used a thematic analysis approach to identify themes discussed within these papers. These themes represent factors that support the effective delivery of patient safety policy initiatives. FINDINGS: Within the discussion papers the authors collated, concerning 11 patient safety policies implemented between 2000 and 2017, five inter-related core themes of capability, culture, systems, candour and leadership were identified. By evaluating these themes and identifying composite sub-themes, a conceptual framework is presented that can be used to support the delivery of patient safety policy initiatives to maximise their impact. ORIGINALITY/VALUE: The conceptual framework the authors illustrate, arising from this new contribution to the body of knowledge, can be translated into a novel self-assessment for individual NHS trusts to understand organisational development areas in the domain of patient safety improvement.

COMplex mental health PAThways (COMPAT) Study: A mixed methods study to inform an evidence-based service delivery model for people with complex needs: Study protocol.

BACKGROUND: Mental health services for adults, as they are currently configured, have been designed to provide predominantly community-based interventions. It has long been recognised that some patients have such significant clinical and/or risk needs that those needs cannot be adequately met within standard service delivery models, resulting in a pressing need to consider the best models for this group of people. This paper shares a protocol for a mixed methods study that aims to understand: the profile and history of service users described as having complex needs; the decision-making processes by clinicians that lead to complex needs categorisation; service users and carers experience of service use; and, associated economic impact. This protocol describes a comprehensive evaluation that aims to inform an evidence-based service delivery model for people with complex needs. METHODS: We will use a mixed methods design, combining quantitative and qualitative methods using in-depth descriptive and inferential analysis of patient records, written medical notes and in-depth interviews with service users, carers, and clinicians. The study will include five components: (1) a quantitative description and analysis of the demographic clinical characteristics of the patient group; (2) an economic evaluation of alternative patient pathways; (3) semi-structured interviews about service user and carer experiences; (4) using data from components 1-3 to co-produce vignettes jointly with relevant stakeholders involved in the care of service users with complex mental health needs; and, (5) semi-structured interviews about clinical decision-making by clinicians in relation to this patient group, using the vignettes as example case studies. DISCUSSION: The study's key outcomes will be to: examine the resource use and cost-impact associated with alternative care pathways to the NHS and other sectors of the economy (including social care); explore patient health and non-health outcomes associated with alternative care pathways; and, gain an understanding of a complex service user group and how treatment decisions are made to inform consistent and person-centred future service delivery.

The empirical evidence base for the use of the HCR-20: A narrative review of study designs and transferability of results to clinical practice.

The HCR-20, a widely used method of assessing and managing risk, relies on the structured professional judgement approach. This paper reports a narrative literature review of the HCR-20 studies to explore the applicability of the study results to the use of the HCR-20 in clinical practice. From a literature search using terms "HCR-20" and "HCR 20", 206 papers were included. Of studies using the HCR-20 version 2 (n = 191), 92% (n = 176) relied on variables based on scores derived by adding item scores, and 50% (n = 95) tested the HCR-20 using predictive validity methodology. Of the HCR-20 version 3 studies (n = 21), the "presence of risk factors" step was the most commonly examined (n = 18, 86%), but 2 of the 7 steps ("scenario planning" and "management") were not examined at all. Amongst those studies whose primary focus was on the HCR-20, 67% (n = 64/95) did so by assessing the predictive validity of the tool. Only one employed a design to test whether the use of the HCR-20 affected violence rates. The predominant study design provides support for the use of the HCR-20 as an actuarial tool, and there is limited empirical evidence in support of its effectiveness as a structured professional judgement approach to the assessment and management of the risk of violence.

Use of Acute Psychiatric Hospitalisation: A Study of the Factors Influencing Decisions to Arrange Acute Admission to Inpatient Mental Health Facilities.

Background: Human decision-making involves a complex interplay of intra- and inter-personal factors. The decisions clinicians make in practise are subject to a wide range of influences. Admission to a psychiatric hospital is a major clinical intervention, but the decision-making processes involved in admissions remain unclear. Aims: To delineate the range of factors influencing clinicians' decisions to arrange acute psychiatric admissions. Methods: We undertook six focus groups with teams centrally involved in decisions to admit patients to hospital (crisis resolution home treatment, liaison psychiatry, approved mental health practitioners and consultant psychiatrists). The data were analysed using qualitative thematic analysis. Results: Our analysis of the data show a complex range of factors influencing decision-making that were categorised as those related to: (i) clinical and risk factors; (ii) fear/threat factors; (iii) interpersonal dynamics; (iv) contextual factors. Conclusions: Decisions to arrange acute admission to hospital are not just based on an appraisal of clinical and risk-related information. Emotional, interpersonal and contextual factors are also critical in decision-making. Delineating the breadth of factors that bear on clinical decision-making can inform approaches to (i) clinical decision-making research, (ii) the training and supervision of clinicians, and (iii) service delivery models.

Predictors of emergency department and GP use among patients with mental health conditions: a public health survey.

BACKGROUND: High demand for health services is an issue of current importance in England, in part because of the rapidly increasing use of emergency departments (EDs) and GP practices for mental health conditions and the high cost of these services. AIM: To examine the social determinants of health service use in people with mental health issues. DESIGN AND SETTING: Twenty-eight neighbourhoods, each with a population of 5000-10 000 people, in the north west coast of England with differing levels of deprivation. METHOD: A comprehensive public health survey was conducted, comprising questions on housing, physical health, mental health, lifestyle, social issues, environment, work, and finances. Poisson regression models assessed the effect of mental health comorbidity, mental and physical health comorbidity, and individual mental health symptoms on ED and general practice attendances, adjusting for relevant socioeconomic and lifestyle factors. RESULTS: Participants who had both a physical and mental health condition reported attending the ED (rate ratio [RR] = 4.63, 95% confidence interval [CI] = 2.86 to 7.51) and general practice (RR = 3.82, 95% CI = 3.16 to 4.62) more frequently than all other groups. Having a higher number of mental health condition symptoms was associated with higher general practice and ED service use. Depression was the only mental health condition symptom that was significantly associated with ED attendance (RR = 1.41, 95% CI = 1.05 to 1.90), and anxiety was the only symptom significantly associated with GP attendance (RR = 1.19, 95% CI = 1.03 to 1.38). CONCLUSION: Mental health comorbidities increase the risk of attendances to both EDs and general practice. Further research into the social attributes that contribute to reduced ED and general practice attendance rates is needed.

A pilot randomised controlled trial of a programme of psychosocial interventions (Resettle) for high risk personality disordered offenders.

BACKGROUND: Offenders with personality disorder experience significant co-morbid mental health problems and present with an increased risk of offending. The evidence for the effectiveness of interventions for personality disordered offenders in the community is limited. This study was a pilot study to determine the feasibility of a randomised controlled trial (RCT) of an intervention known as Resettle for personality disordered offenders and to explore the possible effects of this intervention. METHODS: Potential participants were recruited from referrals of male prisoners to Resettle. Those consenting underwent baseline assessments before being randomised to Resettle or treatment as usual. Officially recorded and self-report offending was assessed over two years following release from custody. Of the 110 eligible participants, 72 (65%) participated in the study of whom 38 were randomised to Resettle and 34 to treatment as usual. The two groups had a similar psychiatric and offending profile. RESULTS: Analysis of officially recorded offences at two years found mixed results, but whether adopting an intent-to-treat approach or including only those who received the intervention there was no clear evidence of an effect of the intervention. A comparison of self-report offending found no effect of Resettle in an intent-to-treat analysis, but there was an effect when the analysis involved only those participating in the intervention. CONCLUSIONS: This study demonstrated that with some adjustments it was possible to carry out an RCT of a complex intervention for personality disordered offenders in a criminal justice setting. Some, but not conclusive, evidence was found in favour of the intervention.

Dynamic relationship between multiple START assessments and violent incidents over time: a prospective cohort study.

BACKGROUND: Dynamic risk factors need to be assessed repeatedly over time rather than at a single time point to examine the relationship with violence. This predictive validity study sought to examine the degree of dynamic change in risk assessed in a group of mentally disordered offenders and the relationship between change and the occurrence of violence. METHODS: Routine structured assessments of Strengths and Vulnerabilities on the Short-Term Assessment of Risk and Treatability (START) instrument (n = 475) were linked prospectively with 275 violent incidents using logistic regression in a sample of 50 patients. RESULTS: Stability within patients estimated using the intra-class correlation coefficient was high (>.80) for both Strengths and Vulnerabilities. In the overall sample, a 10 point increase in START Vulnerabilities score was associated with a three-fold increased risk of violence (OR = 3.1; 95% CI, 1.47-7.46) but there was no association for Strengths score (OR = 0.91, 95% CI, 0.34-2.47). When examined within patients, both Vulnerabilities (OR = 1.77, 95% CI, 0.56-5.54) and Strengths (OR = 2.26, 95% CI, 0.38-13.42) were associated with an increased risk of violence but in both cases precision was low due to reduced sample sizes. CONCLUSIONS: Risk factors which are considered to have the capacity to fluctuate dynamically did not do so substantially in this group of mentally disordered offenders. When fluctuations did occur there was some tentative evidence that they are associated with violent outcomes and could guide the use of prevention measures.

Antiepileptics for aggression and associated impulsivity.

BACKGROUND: Aggression is a major public health issue and is integral to several mental health disorders. Antiepileptic drugs may reduce aggression by acting on the central nervous system to reduce neuronal hyper-excitability associated with aggression. OBJECTIVES: To evaluate the efficacy of antiepileptic drugs in reducing aggression and associated impulsivity. SEARCH STRATEGY: We searched CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, metaRegister of Controlled Trials (mRCT) and ClinicalTrials.gov to April 2009. We also searched Cochrane Schizophrenia Group's register of trials on aggression, National Research Record and handsearched for studies. SELECTION CRITERIA: Prospective, placebo-controlled trials of antiepileptic drugs taken regularly by individuals with recurrent aggression to reduce the frequency or intensity of aggressive outbursts. DATA COLLECTION AND ANALYSIS: Three authors independently selected studies and two authors independently extracted data. We calculated standardised mean differences (SMDs), with odds ratios (ORs) for dichotomous data. MAIN RESULTS: Fourteen studies with data from 672 participants met the inclusion criteria. Five different antiepileptic drugs were examined. Sodium valproate/divalproex was superior to placebo for outpatient men with recurrent impulsive aggression, for impulsively aggressive adults with cluster B personality disorders, and for youths with conduct disorder, but not for children and adolescents with pervasive developmental disorder. Carbamazepine was superior to placebo in reducing acts of self-directed aggression in women with borderline personality disorder, but not in children with conduct disorder. Oxcarbazepine was superior to placebo for verbal aggression and aggression against objects in adult outpatients. Phenytoin was superior to placebo on the frequency of aggressive acts in male prisoners and in outpatient men including those with personality disorder, but not on the frequency of 'behavioral incidents' in delinquent boys. AUTHORS' CONCLUSIONS: The authors consider that the body of evidence summarised in this review is insufficient to allow any firm conclusion to be drawn about the use of antiepileptic medication in the treatment of aggression and associated impulsivity. Four antiepileptics (valproate/divalproex, carbamazepine, oxcarbazepine and phenytoin) were effective, compared to placebo, in reducing aggression in at least one study, although for three drugs (valproate, carbamazepine and phenytoin) at least one other study showed no statistically significant difference between treatment and control conditions. Side effects were more commonly noted for the intervention group although adverse effects were not well reported. Absence of information does not necessarily mean that the treatment is safe, nor that the potential gains from the medication necessarily balance the risk of an adverse event occurring. Further research is needed.

Childhood antecedents of serious violence in adult male offenders.

Prospective longitudinal studies have shown strong predictions from conduct disorders (CDs) in childhood to antisocial personality disorder (ASPD) and violence in adults. However, little is known of the childhood antecedents of serious violence nor whether these may vary depending on the context in which the violence occurs. In this study, 54 men aged 21-40 years serving prison sentences for violent crime were assessed. Standardized interviews of ASPD and violence were conducted independently of interviews covering retrospective recall of childhood psychiatric disorders and adverse experiences. Analyses of the predictors of overall violence suggested a pathway involving childhood CD and adult ASPD associated with interparental discord, and an additional pathway associated with experiencing interparental violence in childhood. Different results were however obtained when account was taken of the context of the violence. The CD-ASPD pathway was associated with social violence, but not with partner violence. Partner violence was predicted by retrospective reports of having been exposed to interparental violence during childhood but not by reports of childhood CD or adult ASPD. Thus developmental pathways to serious violence may be different depending on the social domain in which the violence occurs.