The older prisoner health and social care assessment and plan (OHSCAP) versus treatment as usual: a randomised controlled trial.

BACKGROUND: Older people are the fastest-growing demographic group among prisoners in England and Wales and they have complex health and social care needs. Their care is frequently ad hoc and uncoordinated. No previous research has explored how to identify and appropriately address the needs of older adults in prison. We hypothesised that the Older prisoner Health and Social Care Assessment and Plan (OHSCAP) would significantly increase the proportion of met health and social care needs 3 months after prison entry, compared to treatment as usual (TAU). METHODS: The study was a parallel randomised controlled trial (RCT) recruiting male prisoners aged 50 and over from 10 prisons in northern England. Participants received the OHSCAP or TAU. A clinical trials unit used minimisation with a random element as the allocation procedure. Data analysis was conducted blind to allocation status. The intervention group had their needs assessed using the OHSCAP tool and care plans were devised; processes that lasted approximately 30 min in total per prisoner. TAU included the standard prison health assessment and care. The intention to treat principle was followed. The trial was registered with the UK Clinical Research Network Portfolio (ISRCTN ID: 11841493) and was closed on 30 November 2016. RESULTS: Data were collected between 28 January 2014 and 06 April 2016. Two hundred and forty nine older prisoners were assigned TAU of which 32 transferred prison; 12 were released; 2 withdrew and 1 was deemed unsafe to interview. Two hundred and fifty three 3 prisoners were assigned the OHSCAP of which 33 transferred prison; 11 were released; 6 withdrew and 1 was deemed unsafe to interview. Consequently, data from 202 participants were analysed in each of the two groups. There were no significant differences in the number of unmet needs as measured by the Camberwell Assessment of Needs - Forensic Short Version (CANFOR-S). The mean number of unmet needs for the OHSCAP group at follow-up was 2.03 (SD = 2.07) and 2.06 (SD = 2.11) for the TAU group (mean difference = 0.088; 95% CI - 0.276 to 0.449, p = 0.621). No adverse events were reported. CONCLUSION: The OHSCAP was fundamentally not implemented as planned, partly due to the national prison staffing crisis that ensued during the study period. Therefore, those receiving the OHSCAP did not experience improved outcomes compared to those who received TAU. TRIAL REGISTRATION: Current Controlled Trials: ISRCTN11841493 , 25/10/2012.

Psychiatric disorders, substance use, and executive functioning in older probationers.

Background: Although the number of older people serving community sentences (probation) after conviction for a criminal offence in England and Wales has increased rapidly since about 2006, this population has received little research attention. Aim: To examine the mental health, substance use, and executive functioning of older probationers. Methods: Thirty­two male probationers aged 50 years and older were recruited from probation services in the Thames Valley, England, and administered validated semistructured interviews for psychiatric disorders, symptom checklists for depression and substance use, cognitive impairment screens, and neuropsychological tests of executive functioning (examining verbal fluency and response inhibition). Results: We found that older probationers presented with a high prevalence of mental health difficulties (overall caseness n = 22; 69%, 95% CI [53­85]) that exceed estimates in the older general population. Prevalences of depression (25%) or alcohol abuse or dependence (19%) were found to be high. In comparison with normative data, however, older probationers did not present with deficits in tested executive functioning. Conclusions and implications for practice: Mental health and substance use problems were more prominent than cognitive deficits in this sample of older probationers. Further work should include older community controls to inform service planning and to determine how these mental health factors interact with offending.

Links between depressive symptoms and unmet health and social care needs among older prisoners.

BACKGROUND: absolute numbers of older prisoners and their proportion of the total prison population are increasing. They have multiple health and social care needs that are prominent on entry into prison. No previous studies have identified older prisoners' health and social care needs at this crucial point. OBJECTIVE: to examine unmet health and social care needs among older men entering prison and their links with depressive symptoms. METHODS: a cross-sectional survey across nine prisons in the North of England was completed. One hundred male prisoners aged between 60 and 81 were interviewed, using the Camberwell Assessment of Need-Forensic short version (CANFOR-S) and Geriatric Depression Scale-Short Form (GDS-15). Descriptive statistics were generated and χ(2) tests performed. RESULTS: participants reported high levels of unmet needs as measured with the CANFOR-S, notably in the domains of knowledge about their condition and treatment (38%); psychological distress (34%); daytime activities (29%); benefits (28%); food (22%) and physical health (21%). The mean total number of unmet needs was 2.74, with a median of 2.0. More than half the sample (56%, 95% CI 45-66%) exhibited clinical signs of depression. A significant association between depressive symptomology and an unmet physical health need, as measured by the CANFOR-S, was detected (χ(2) = 6.76, df = 1, P < 0.01). CONCLUSIONS: high levels of depressive symptoms were experienced by older prisoners on entry into prison. Personalised health and social care needs assessment and discrete depression screening are required on prison entry to facilitate effective management of unmet needs.

Improving awareness of patient safety in a peer-led pilot educational programme for undergraduate medical students.

BACKGROUND: Patient safety is becoming an important but under-emphasised topic in medical education. Despite high-profile recommendations, it has not yet been ingrained in the medical undergraduate curriculum. We designed and evaluated an educational intervention on patient safety to pre-clinical undergraduate medical students, devised and run entirely by medical students in their clinical years. The aim was to raise awareness of patient safety, and provide the opportunity to practice specific skills useful as medical students and junior doctors. METHODS: We designed a two hour seminar consisting of a brief lecture on the principles of patient safety, followed by a carousel of interactive activities in small groups. Attendance was voluntary. The effects were evaluated by questionnaires addressing satisfaction, attitudes and self-efficacy completed before, after and six months following the seminar. RESULTS: A total of 86 students attended, with a reserve list of interested students in place. A total of 92% completed the pre- and post-evaluation, of whom 100% enjoyed the seminar, 99% recommended other students to take part and 92% thought it should be a mandatory part of the curriculum. A total of 64% completed follow-up questionnaires at six months and showed significant maintenance of skills taught. DISCUSSION: Student tutors can deliver effective and engaging teaching on patient safety and should be utilised as part of the existing medical curriculum. Patient safety should be taught at medical schools using interactive methodologies to promote interest.

Social and custodial needs of older adults in prison.

BACKGROUND: older prisoners are a fast-growing group but there is limited evidence for how well their needs are being met. OBJECTIVES: to quantify the social and custodial needs of older prisoners and suggest improvements for service provision. DESIGN: cross-sectional study. SETTING: twelve prisons holding adult males in North West England. SUBJECTS: two hundred and sixty-two prisoners; 97 aged between 50 and 59, 165 aged 60 and over. METHODS: interview and case-note review for issues of social and custodial need and quality of life in prison, including Forensic Camberwell Assessment of Need and Lubben Scale for social networks. RESULTS: many had problems mixing with younger prisoners, accommodation and activities, and limited contact with friends and family. A small group had personal care needs which were not well managed in prison. CONCLUSION: older prisoners have distinct social and custodial needs which need to be addressed by a national strategy for their care and management.

The health and social needs of older male prisoners.

OBJECTIVES: This study aimed to quantify the health and social needs of older male prisoners in the North West of England, to determine whether their needs were being met, and to explore an age cut-off for this group. METHODS: Data were collected by interview and case note review. Areas covered included physical health, mental health, personality disorder, cognitive impairment and social need. RESULTS: A total of 262 prisoners were included in the study. Over 90% had a physical health disorder, most commonly hypertension and osteoarthritis. A total of 61% had a mental disorder, most commonly major depressive disorder and alcohol misuse disorder. There were few differences within age bands for physical health problem or health/social need, but those aged 50-59 years had more mental disorder, including mental illness, substance misuse disorder and personality disorder. CONCLUSIONS: Older prisoners have a high level of health need and a different profile to the rest of the prison population. Fifty appears to be a useful age over which to define this group, and service provision should reflect this in a national management strategy.

Improvements to suicide prevention training for prison staff in England and Wales.

Suicide prevention training for the prison service in England and Wales has been criticized. STORM is a package emphasizing the practice and review of interactions with suicidal persons and was evaluated in a pilot study for use in prisons. Trainees completed questionnaires immediately before and after training and at 6 to 8 months follow-up. Training significantly improved attitudes, knowledge, and confidence, and improvements were maintained at follow-up. Satisfaction with training was very high. STORM was successfully adapted for prison settings, and showed good effects among staff trained. It should be provided to the wider prison estate, with regular refresher training.

Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: a systematic review and network meta-analysis.

BACKGROUND: The benefits and safety of medications for attention-deficit hyperactivity disorder (ADHD) remain controversial, and guidelines are inconsistent on which medications are preferred across different age groups. We aimed to estimate the comparative efficacy and tolerability of oral medications for ADHD in children, adolescents, and adults. METHODS: We did a literature search for published and unpublished double-blind randomised controlled trials comparing amphetamines (including lisdexamfetamine), atomoxetine, bupropion, clonidine, guanfacine, methylphenidate, and modafinil with each other or placebo. We systematically contacted study authors and drug manufacturers for additional information. Primary outcomes were efficacy (change in severity of ADHD core symptoms based on teachers' and clinicians' ratings) and tolerability (proportion of patients who dropped out of studies because of side-effects) at timepoints closest to 12 weeks, 26 weeks, and 52 weeks. We estimated summary odds ratios (ORs) and standardised mean differences (SMDs) using pairwise and network meta-analysis with random effects. We assessed the risk of bias of individual studies with the Cochrane risk of bias tool and confidence of estimates with the Grading of Recommendations Assessment, Development, and Evaluation approach for network meta-analyses. This study is registered with PROSPERO, number CRD42014008976. FINDINGS: 133 double-blind randomised controlled trials (81 in children and adolescents, 51 in adults, and one in both) were included. The analysis of efficacy closest to 12 weeks was based on 10 068 children and adolescents and 8131 adults; the analysis of tolerability was based on 11 018 children and adolescents and 5362 adults. The confidence of estimates varied from high or moderate (for some comparisons) to low or very low (for most indirect comparisons). For ADHD core symptoms rated by clinicians in children and adolescents closest to 12 weeks, all included drugs were superior to placebo (eg, SMD -1·02, 95% CI -1·19 to -0·85 for amphetamines, -0·78, -0·93 to -0·62 for methylphenidate, -0·56, -0·66 to -0·45 for atomoxetine). By contrast, for available comparisons based on teachers' ratings, only methylphenidate (SMD -0·82, 95% CI -1·16 to -0·48) and modafinil (-0·76, -1·15 to -0·37) were more efficacious than placebo. In adults (clinicians' ratings), amphetamines (SMD -0·79, 95% CI -0·99 to -0·58), methylphenidate (-0·49, -0·64 to -0·35), bupropion (-0·46, -0·85 to -0·07), and atomoxetine (-0·45, -0·58 to -0·32), but not modafinil (0·16, -0·28 to 0·59), were better than placebo. With respect to tolerability, amphetamines were inferior to placebo in both children and adolescents (odds ratio [OR] 2·30, 95% CI 1·36-3·89) and adults (3·26, 1·54-6·92); guanfacine was inferior to placebo in children and adolescents only (2·64, 1·20-5·81); and atomoxetine (2·33, 1·28-4·25), methylphenidate (2·39, 1·40-4·08), and modafinil (4·01, 1·42-11·33) were less well tolerated than placebo in adults only. In head-to-head comparisons, only differences in efficacy (clinicians' ratings) were found, favouring amphetamines over modafinil, atomoxetine, and methylphenidate in both children and adolescents (SMDs -0·46 to -0·24) and adults (-0·94 to -0·29). We did not find sufficient data for the 26-week and 52-week timepoints. INTERPRETATION: Our findings represent the most comprehensive available evidence base to inform patients, families, clinicians, guideline developers, and policymakers on the choice of ADHD medications across age groups. Taking into account both efficacy and safety, evidence from this meta-analysis supports methylphenidate in children and adolescents, and amphetamines in adults, as preferred first-choice medications for the short-term treatment of ADHD. New research should be funded urgently to assess long-term effects of these drugs. FUNDING: Stichting Eunethydis (European Network for Hyperkinetic Disorders), and the UK National Institute for Health Research Oxford Health Biomedical Research Centre.

Substance use disorders in prisoners: an updated systematic review and meta-regression analysis in recently incarcerated men and women.

AIMS: The aims were to (1) estimate the prevalence of alcohol and drug use disorders in prisoners on reception to prison and (2) estimate and test sources of between study heterogeneity. METHODS: Studies reporting the 12-month prevalence of alcohol and drug use disorders in prisoners on reception to prison from 1 January 1966 to 11 August 2015 were identified from seven bibliographic indexes. Primary studies involving clinical interviews or validated instruments leading to DSM or ICD diagnoses were included; self-report surveys and investigations that assessed individuals more than 3 months after arrival to prison were not. Random-effects meta-analysis and subgroup and meta-regression analyses were conducted. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. RESULTS: In total, 24 studies with a total of 18 388 prisoners across 10 countries were identified. The random-effects pooled prevalence estimate of alcohol use disorder was 24% [95% confidence interval (CI) = 21-27], with very high heterogeneity (I2  = 94%). These ranged from 16 to 51% in male and 10-30% in female prisoners. For drug use disorders, there was evidence of heterogeneity by sex, and the pooled prevalence estimate in male prisoners was 30% (95% CI = 22-38; I2  = 98%; 13 studies; range 10-61%) and, in female prisoners, was 51% (95% CI = 43-58; I2  = 95%; 10 studies; range 30-69%). On meta-regression, sources of heterogeneity included higher prevalence of drug use disorders in women, increasing rates of drug use disorders in recent decades, and participation rate. CONCLUSIONS: Substance use disorders are highly prevalent in prisoners. Approximately a quarter of newly incarcerated prisoners of both sexes had an alcohol use disorder, and the prevalence of a drug use disorder was at least as high in men, and higher in women.

Comparative efficacy and tolerability of pharmacological interventions for attention-deficit/hyperactivity disorder in children, adolescents and adults: protocol for a systematic review and network meta-analysis.

INTRODUCTION: Attention-deficit/hyperactivity disorder (ADHD) is a major public health issue. Pharmacological treatments play an important role in the multimodal treatment of ADHD. Currently, there is a lack of up-to-date and comprehensive evidence on how available ADHD drugs compare and rank in terms of efficacy and tolerability, in children or adolescents as well as in adults. We will conduct a network meta-analysis (NMA), integrating direct and indirect comparisons from randomised controlled trials (RCTs), to rank pharmacological treatments for ADHD according to their efficacy and tolerability profiles. METHODS AND ANALYSIS: We will search a broad range of electronic databases, including PubMed, MEDLINE, EMBASE, PsycINFO, ERIC and Web of Science, with no date or language restrictions. We will also search for unpublished studies using international clinical trial registries and contacting relevant drug companies. We will identify and include available parallel-group, cross-over and cluster randomised trials that compare methylphenidate, dexmethylphenidate, amphetamine derivatives (including lisdexamfetamine), atomoxetine, clonidine, guanfacine, bupropion or modafinil (as oral therapy) either with each other or to placebo, in children, adolescents or adults with ADHD. Primary outcomes will be efficacy (indicated by reduction in severity of ADHD core symptoms measured on a standardised scale) and tolerability (the proportion of patients who left a study early due to side effects). Secondary outcomes will be global functioning, acceptability (proportion of patients who left the study early by any cause) and changes in blood pressure and body weight. NMA will be conducted in STATA within a frequentist framework. The quality of RCTs will be evaluated using the Cochrane risk of bias tool, and the quality of the evidence will be assessed using the GRADE approach. Subgroup and sensitivity analyses will be conducted to assess the robustness of the findings. ETHICS AND DISSEMINATION: No ethical issues are foreseen. Results from this study will be published in a peer-reviewed journal and possibly presented at relevant national and international conferences. TRIAL REGISTRATION NUMBER: CRD42014008976.

Mental health of prisoners: prevalence, adverse outcomes, and interventions.

More than 10 million people are imprisoned worldwide, and the prevalence of all investigated mental disorders is higher in prisoners than in the general population. Although the extent to which prison increases the incidence of mental disorders is uncertain, considerable evidence suggests low rates of identification and treatment of psychiatric disorders. Prisoners are also at increased risk of all-cause mortality, suicide, self-harm, violence, and victimisation, and research has outlined some modifiable risk factors. Few high quality treatment trials have been done on psychiatric disorders in prisoners. Despite this lack of evidence, trial data have shown that opiate substitution treatments reduce substance misuse relapse and possibly reoffending. The mental health needs of women and older adults in prison are distinct, and national policies should be developed to meet these. In this Review, we present clinical, research, and policy recommendations to improve mental health care in prisons. National attempts to meet these recommendations should be annually surveyed.

Evaluating a split processing model of visual word recognition: effects of orthographic neighborhood size.

The split fovea theory proposes that visual word recognition of centrally presented words is mediated by the splitting of the foveal image, with letters to the left of fixation being projected to the right hemisphere (RH) and letters to the right of fixation being projected to the left hemisphere (LH). Two lexical decision experiments aimed to elucidate word recognition processes under the split fovea theory are described. The first experiment showed that when words were presented centrally, such that the initial letters were in the left visual field (LVF/RH), there were effects of orthographic neighborhood, i.e., there were faster responses to words with high rather than low orthographic neighborhoods for the initial letters ('lead neighbors'). This effect was limited to lead-neighbors but not end-neighbors (orthographic neighbors sharing the same final letters). When the same words were fully presented in the LVF/RH or right visual field (RVF/LH, Experiment 2), there was no effect of orthographic neighborhood size. We argue that the lack of an effect in Experiment 2 was due to exposure to all of the letters of the words, the words being matched for overall orthographic neighborhood count and the sub-parts no longer having a unique effect. We concluded that the orthographic activation found in Experiment 1 occurred because the initial letters of centrally presented words were projected to the RH. The results support the split fovea theory, where the RH has primacy in representing lead neighbors of a written word.

Handedness, measures of hemispheric asymmetry, and lateralised lexical decision.

The goals of the present study were to evaluate the differences between measures of lateralisation in the human brain derived from a dichotic listening (DL) task and from a task involving identification of visually presented consonant-vowel-consonant (CVC) nonwords, and to correlate these lateralisation indices with performance on a lexical decision task involving visually presented words and nonwords. Visual stimuli were presented either in a central position, or to the left or right of fixation. Left-handed and right-handed participants completed each of the three tasks. Lateralisation indices were derived from performance on the DL and CVC tasks, and latency and accuracy measures of lexical decision performance were obtained for targets presented centrally and parafoveally. Lateralisation indices for left-handed and right-handed participants differed significantly for both tasks, and the two lateralisation indices had different pattern of correlation with lexical decision performance for left- and right-handers. For left-handers, lateralisation indices derived from the (visual) CVC task were correlated with lexical decision response latency for targets in central and left visual field. For right-handers, lateralisation indices derived from the (auditory) DL task were correlated with lexical decision response latency for targets in central and right visual field. A possible explanation for this finding is that the two laterality measures reflect specialisation for different types of linguistic processing in the human brain.