The nature of the pathway from conduct disorder (CD) in adolescence to antisocial behavior in adulthood has been debated and the role of certain mediators remains unclear. One perspective is that CD forms part of a general psychopathology dimension, playing a central role in the developmental trajectory. Impairment in reflective functioning (RF), i.e., the capacity to understand one's own and others' mental states, may relate to CD, psychopathology, and aggression. Here, we characterized the structure of psychopathology in adult male-offenders and its role, along with RF, in mediating the relationship between CD in their adolescence and current aggression.

A secondary analysis of pre-treatment data from 313 probation-supervised offenders was conducted, and measures of CD symptoms, general and specific psychopathology factors, RF, and aggression were evaluated through clinical interviews and questionnaires.

Confirmatory factor analyses indicated that a bifactor model best fitted the sample's psychopathology structure, including a general psychopathology factor (p factor) and five specific factors: internalizing, disinhibition, detachment, antagonism, and psychoticism. The structure of RF was fitted to the data using a one-factor model. According to our mediation model, CD significantly predicted the p factor, which was positively linked to RF impairments, resulting in increased aggression.

These findings highlight the critical role of a transdiagnostic approach provided by RF and general psychopathology in explaining the link between CD and aggression. Furthermore, they underscore the potential utility of treatments focusing on RF, such as mentalization-based treatment, in mitigating aggression in offenders with diverse psychopathologies.

National guidance cautions against low-intensity interventions for people with personality disorder, but evidence from trials is lacking.

To test the feasibility of conducting a randomised trial of a low-intensity intervention for people with personality disorder.

Single-blind, feasibility trial (trial registration: ISRCTN14994755). We recruited people aged 18 or over with a clinical diagnosis of personality disorder from mental health services, excluding those with a coexisting organic or psychotic mental disorder. We randomly allocated participants via a remote system on a 1:1 ratio to six to ten sessions of Structured Psychological Support (SPS) or to treatment as usual. We assessed social functioning, mental health, health-related quality of life, satisfaction with care and resource use and costs at baseline and 24 weeks after randomisation.

A total of 63 participants were randomly assigned to either SPS (n = 33) or treatment as usual (n = 30). Twenty-nine (88%) of those in the active arm of the trial received one or more session (median 7). Among 46 (73%) who were followed up at 24 weeks, social dysfunction was lower (−6.3, 95% CI −12.0 to −0.6, P = 0.03) and satisfaction with care was higher (6.5, 95% CI 2.5 to 10.4; P = 0.002) in those allocated to SPS. Statistically significant differences were not found in other outcomes. The cost of the intervention was low and total costs over 24 weeks were similar in both groups.

SPS may provide an effective low-intensity intervention for people with personality disorder and should be tested in fully powered clinical trials.

Substantial policy, communication and operational gaps exist between mental health services and the police for individuals with enduring mental health needs.

To map and cost pathways through mental health and police services, and to model the cost impact of implementing key policy recommendations.

Within a case-linkage study, we estimated 1-year individual-level healthcare and policing costs. Using decision modelling, we then estimated the potential impact on costs of three recommended service enhancements: street triage, Mental Health Act assessments for all Section 136 detainees and outreach custody link workers.

Under current care, average 1-year mental health and police costs were £10 812 and £4552 per individual respectively (n = 55). The cost per police incident was £522. Models suggested that each service enhancement would alter per incident costs by between −8% and +6%.

Recommended enhancements to care pathways only marginally increase individual-level costs.

Health anxiety, hypochondriasis and personality disturbance commonly coexist. The impact of personality status was assessed in a secondary analysis of a randomised controlled trial (RCT).

To test the impact of personality status using ICD-11 criteria on the clinical and cost outcomes of treatment with cognitive–behavioural therapy for health anxiety (CBT-HA) and standard care over 2 years.

Personality dysfunction was assessed at baseline in 444 patients before randomisation and independent assessment of costs and outcomes made on four occasions over 2 years.

In total, 381 patients (86%) had some personality dysfunction with 184 (41%) satisfying the ICD criteria for personality disorder. Those with no personality dysfunction showed no treatment differences (P = 0.90) and worse social function with CBT-HA compared with standard care (P<0.03) whereas all other personality groups showed greater improvement with CBT-HA maintained over 2 years (P<0.001). Less benefit was shown in those with more severe personality disorder (P<0.05). Costs were less with CBT-HA except for non-significant greater differences in those with moderate or severe personality disorder.

The results contradict the hypothesis that personality disorder impairs response to CBT in health anxiety in both the short and medium term.

Reports linking the deinstitutionalisation of psychiatric care with homelessness and imprisonment have been published widely.

To identify cohort studies that followed up or traced back long-term psychiatric hospital residents who had been discharged as a consequence of deinstitutionalisation.

A broad search strategy was used and 9435 titles and abstracts were screened, 416 full articles reviewed and 171 articles from cohort studies of deinstitutionalised patients were examined in detail.

Twenty-three studies of unique populations assessed homelessness and imprisonment among patients discharged from long-term care. Homelessness and imprisonment occurred sporadically; in the majority of studies no single case of homelessness or imprisonment was reported.

Our results contradict the findings of ecological studies which indicated a strong correlation between the decreasing number of psychiatric beds and an increasing number of people with mental health problems who were homeless or in prison.

Despite evidence of the effectiveness of injectable opioid treatment compared with oral methadone for chronic heroin addiction, the additional cost of injectable treatment is considerable, and cost-effectiveness uncertain.

To compare the cost-effectiveness of supervised injectable heroin and injectable methadone with optimised oral methadone for chronic refractory heroin addiction.

Multisite, open-label, randomised controlled trial. Outcomes were assessed in terms of quality-adjusted life-years (QALYs). Economic perspective included health, social services and criminal justice resources.

Intervention costs over 26 weeks were significantly higher for injectable heroin (mean £8995 v. £4674 injectable methadone and £2596 oral methadone; P<0.0001). Costs overall were highest for oral methadone (mean £15805 v. £13410 injectable heroin and £10945 injectable methadone; P =n.s.) due to higher costs of criminal activity. In cost-effectiveness analysis, oral methadone was dominated by injectable heroin and injectable methadone (more expensive and less effective). At willingness to pay of £30 000 per QALY, there is a higher probability of injectable methadone being more cost-effective (80%) than injectable heroin.

Injectable opioid treatments are more cost-effective than optimised oral methadone for chronic refractory heroin addiction. The choice between supervised injectable heroin and injectable methadone is less clear. There is currently evidence to suggest superior effectiveness of injectable heroin but at a cost that policy makers may find unacceptable. Future research should consider the use of decision analytic techniques to model expected costs and benefits of the treatments over the longer term.

People with borderline personality disorder frequently experience crises. To date, no randomised controlled trials (RCTs) of crisis interventions for this population have been published.

To examine the feasibility of recruiting and retaining adults with borderline personality disorder to a pilot RCT investigating the potential efficacy and cost-effectiveness of using a joint crisis plan.

An RCT of joint crisis plans for community-dwelling adults with borderline personality disorder (trial registration: ISRCTN12440268). The primary outcome measure was the occurrence of self-harming behaviour over the 6-month period following randomisation. Secondary outcomes included depression, anxiety, engagement and satisfaction with services, quality of life, well-being and cost-effectiveness.

In total, 88 adults out of the 133 referred were eligible and were randomised to receive a joint crisis plan in addition to treatment as usual (TAU; n=46) or TAU alone (n=42). This represented approximately 75% of our target sample size and follow-up data were collected on 73 (83.0%) participants. Intention-to-treat analysis revealed no significant differences in the proportion of participants who reported self-harming (odds ratio (OR) =1.9, 95% CI 0.53-6.5,P = 0.33) or the frequency of self-harming behaviour (rate ratio (RR)=0.74, 95% CI 0.34-1.63, P=0.46) between the two groups at follow-up. No significant differences were observed between the two groups on any of the secondary outcome measures or costs.

It is feasible to recruit and retain people with borderline personality disorder to a trial of joint crisis plans and the intervention appears to have high face validity with this population. However, we found no evidence of clinical efficacy in this feasibility study.

The dangerous severe personality disorder programme was developed in high secure prisons and hospitals at great expense to identify and treat the most dangerous offenders with personality disorders.

To evaluate whether the long-term costs of the programme are greater or less than the long-term outcomes.

We used a Markov decision model with a cost-effectiveness analysis to determine the incremental cost of the programme per serious offence prevented and a cost-offset analysis to consider whether monetary benefits were greater than costs.

Costs were consistently higher for the intervention programme and the cost per serious offence prevented was over £2 million, although there was some evidence that adjustments to the programme could lead to similar interventions becoming cost-effective.

Little evidence was found to support the cost-effectiveness of the intervention programme for offenders with personality disorders, although delivery of the programme in a lower-cost prison would probably yield greater benefits than costs. There are frequent calls for mentally disordered offenders to be detained in secure hospitals rather than prisons; however, if reoffending remains the outcome of interest for policy makers, it is likely that the costs of detention in hospital will remain greater than the benefits for dangerous offenders with a personality disorder.

To examine the clinical outcome and bed usage in patients with comorbid substance misuse and psychosis. The patients were randomised to ordinary assertive outreach team care or to enhanced assertive outreach with nidotherapy. Ratings of clinical symptoms, social function, engagement with services, bed usage (primary outcome after 1 year) and economic costs were assessed at baseline and at 6 and 12 months after randomisation.

Patients referred to nidotherapy had similar reduction in symptoms and engagement, with marginal superiority in social function (P = 0.045). There was a 110% reduction in hospital bed use after 1 year compared with control assertive care (P = 0.03). The mean cost savings for each patient allocated to nidotherapy was £14705 per year, mainly as a consequence of reduced psychiatric bed use.

Nidotherapy shows promise in the treatment of substance misuse and psychosis and may reduce hospital bed usage.

Little is known about the management of health anxiety and hypochondriasis in secondary care settings.

To determine whether cognitive–behavioural therapy (CBT) along with a supplementary manual was effective in reducing symptoms and health consultations in patients with high health anxiety in a genitourinary medicine clinic.

Patients with high health anxiety were randomly assigned to brief CBT and compared with a control group.

Greater improvement was seen in Health Anxiety Inventory (HAI) scores (primary outcome) in patients treated with CBT (n=23) than in the control group (n=26) (P=0.001). Similar but less marked differences were found for secondary outcomes of generalised anxiety, depression and social function, and there were fewer health service consultations. The CBT intervention resulted in improvements in outcomes alongside higher costs, with an incremental cost of £33 per unit reduction in HAI score.

Cognitive–behavioural therapy for health anxiety within a genitourinary medicine clinic is effective and suggests wider use of this intervention in medical settings.