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People with mental disorders can receive treatment in the community. Some, however, fall out of services and into the criminal justice system, running the risk of imprisonment and a deteriorating mental health cycle. This editorial describes Mental Health Treatment Requirements (MHTRs), that is court-imposed sentences that enable people in the UK to access treatment in the community and divert them from short custodial sentences. MHTRs have proven successful for people with primary care mental health needs. It remains difficult to secure these sentences for people with secondary care mental health needs. Three new ‘proof of concept’ sites for secondary care MHTRs may help understand barriers and find solutions.
Forensic psychiatry, of all the specialties in medicine, needs its own strong academic core. Academic forensic psychiatry is founded in scientific research, with its systematic approach to making and recording observations, formulating hypotheses from them, testing those hypotheses with new observations and accumulating the most comprehensive picture possible in a way that is transparent and replicable. An academic approach supports application of scientific principles as strongly in the individual case as in developing relevant collective knowledge, is able to make links between them and can communicate all this effectively within and outside the specialty. This requires highly developed and defined specialist training. Academic forensic psychiatry in this sense is the business of all forensic psychiatrists. In order for forensic psychiatry to thrive, however, it is vital that some forensic psychiatrists further specialise in academic work in terms of additional training, time and immersion in skills that support accurate scientific questioning and testing and, ultimately, the capacity to innovate and keep this cycle active.
In May 2021, the Scientific Advisory Committee on Nutrition (SACN) published a risk assessment on lower carbohydrate diets for adults with type 2 diabetes (T2D)(1). The purpose of the report was to review the evidence on ‘low’-carbohydrate diets compared with the current UK government advice on carbohydrate intake for adults with T2D. However, since there is no agreed and widely utilised definition of a ‘low’-carbohydrate diet, comparisons in the report were between lower and higher carbohydrate diets. SACN’s remit is to assess the risks and benefits of nutrients, dietary patterns, food or food components for health by evaluating scientific evidence and to make dietary recommendations for the UK based on its assessment(2). SACN has a public health focus and only considers evidence in healthy populations unless specifically requested to do otherwise. Since the Committee does not usually make recommendations relating to clinical conditions, a joint working group (WG) was established in 2017 to consider this issue. The WG comprised members of SACN and members nominated by Diabetes UK, the British Dietetic Association, Royal College of Physicians and Royal College of General Practitioners. Representatives from NHS England and NHS Health Improvement, the National Institute for Health and Care Excellence and devolved health departments were also invited to observe the WG. The WG was jointly chaired by SACN and Diabetes UK.
The new Sentencing Council Guideline on sentencing offenders with mental disorders, effective from 1 October 2020, is essential reading for all psychiatrists who give evidence in the criminal courts, revealing something of required judicial thinking, our common ground on public safety concerns but differences in focus on culpability and punishment.
To understand experience of early imprisonment in one prison under low staffing levels. A researcher, independent of the prison, interviewed each prisoner soon after reception and 3–4 weeks later. The first question of the second interview was: ‘I’d like to start by asking you about your experience of the last 3–4 weeks in prison'. Data are verbatim answers to this. Narratives were brief, so responses from all 130 participants were analysed, using grounded theory methods.
Results
The core experience was of ‘routine’ – characterised by repetitive acts of daily living and basic work, and little reference to life outside prison – generally resolved passively, towards boredom and ‘entrapment’.
Clinical implications
This ‘routine’ seems akin to the ‘institutionalism’ described in the end days of the 1960s’ mental hospitals. In an earlier study of similar men at a similar stage of imprisonment, under higher staff:prisoner ratios, experience was initially more distressing, but resolved actively and positively, suggesting that staff loss may have affected rehabilitative climate.
This collection of essays pays tribute to Nancy Freeman Regalado, a ground-breaking scholar in the field of medieval French literature whose research has always pushed beyond disciplinary boundaries. The articles in the volume reflect the depth and diversity of her scholarship, as well as her collaborations with literary critics, philologists, historians, art historians, musicologists, and vocalists - in France, England, and the United States. Inspired by her most recent work, these twenty-four essays are tied together by a single question, rich in ramifications: how does performance shape our understanding of medieval and pre-modern literature and culture, whether the nature of that performance is visual, linguistic, theatrical, musical, religious, didactic, socio-political, or editorial? The studies presented here invite us to look afresh at the interrelationship of audience, author, text, and artifact, to imagine new ways of conceptualizing the creation, transmission, and reception of medieval literature, music, and art.
EGLAL DOSS-QUINBY is Professor of French at Smith College; ROBERTA L. KRUEGER is Professor of French at Hamilton College; E. JANE BURNS is Professor of Women's Studies and Adjunct Professor of Comparative Literature at the University of North Carolina, Chapel Hill.
Contributors: ANNE AZÉMA, RENATE BLUMENFELD-KOSINSKI, CYNTHIA J. BROWN, ELIZABETH A. R. BROWN, MATILDA TOMARYN BRUCKNER, E. JANE BURNS, ARDIS BUTTERFIELD, KIMBERLEE CAMPBELL, ROBERT L. A. CLARK, MARK CRUSE, KATHRYN A. DUYS, ELIZABETH EMERY, SYLVIA HUOT, MARILYN LAWRENCE, KATHLEEN A. LOYSEN, LAURIE POSTLEWATE, EDWARD H. ROESNER, SAMUEL N. ROSENBERG, LUCY FREEMAN SANDLER, PAMELA SHEINGORN, HELEN SOLTERER, JANE H. M. TAYLOR, EVELYN BIRGE VITZ, LORI J. WALTERS, AND MICHEL ZINK.
There is evidence that changing diagnoses may be an important factor preceding homicide, but there is little literature on diagnostic antecedents to admission to specialist secure units after violent behaviour. Our aim was to establish the frequency of a history of changing diagnoses in patients in a UK specialist unit, and to explore the characteristics of these patients.
Results
In total, 38 of 42 study participants had prior contact with psychiatric services. Just over 40% (16 of the 38) had had their diagnosis changed three or more times. All those who had major changes in their diagnosis had received a diagnosis of a psychotic illness at some point prior to the secure unit admission, but then had it withdrawn, only to be restored after prolonged assessment in the secure unit. Personality disorder and substance misuse comorbidity was common in this group; however, non-psychotic diagnoses were seen as more important than psychotic diagnoses by general services.
Clinical implications
Changes in diagnosis between first presentation to psychiatric services and admission to a medium-security unit were more common than would be expected from reports in the general literature. They are a testimony to the difficulties experienced by service providers in delivering a consistent service. This needs to be studied further.
Individuals with repetitive or impulsive aggression in the absence of
other disorders may be diagnosed with intermittent explosive disorder
according to DSM–IV, but no such diagnostic category exists in ICD–10.
Mood stabilisers are often used off-license for the treatment of
aggression associated with a variety of psychiatric conditions, but their
efficacy in these and in idiopathic aggression is not known.
Aims
To summarise and evaluate the evidence for the efficacy of mood
stabilisers (anticonvulsants/lithium) in the treatment of impulsive or
repetitive aggression in adults.
Method
A meta-analysis of randomised controlled trials that compared a mood
stabiliser with placebo in adults without intellectual disability,
organic brain disorder or psychotic illness, identified as exhibiting
repetitive or impulsive aggression.
Results
Ten eligible trials (489 participants) were identified A pooled analysis
showed an overall significant reduction in the frequency/severity of
aggressive behaviour (standardised mean difference (SMD) =–1.02, 95% CI
−1.54 to −0.50), although heterogeneity was high (I2 = 84.7%). When analysed by drug type, significant effects
were found in the pooled analysis of three phenytoin trials (SMD =–1.34,
95% CI −2.16 to −0.52), one lithium trial (SMD =–0.81, 95% CI −1.35 to
−0.28), and two oxcarbazepine/carbamazepine trials (SMD =–1.20, 95% CI
−1.83 to −0.56). However, when the results of only those studies that had
a low risk of bias were pooled (347 participants), there was no
significant reduction in aggression (SMD =–0.28, 95% CI −0.73 to 0.17,
I2 = 71.4%).
Conclusions
There is evidence that mood stabilisers as a group are significantly
better than placebo in reducing aggressive behaviour, but not all mood
stabilisers appear to share this effect. There is evidence of efficacy
for carbamazepine/oxcarbazepine, phenytoin and lithium. Many studies,
however, were at risk of bias and so further randomised controlled trials
are recommended.
Seventy-one men completed a battery of cognitive tests which were designed to reflect verbal analytic and non-verbal holistic functioning. Interest centred around pattern of response. Thirty men were suffering from an affective disorder and forty-one were well. All the men were in prison, the majority awaiting trial. The affective disorder group was subdivided into three categories: men who had a history of manic-depressive illness; a group of unipolar, psychotically depressed men; and men who were regarded as being depressed in reaction to circumstances. All three groups showed specific difficulty in dealing with spatial/holistic tasks, other factors being held constant. They were also found to differ in a number of other respects. The possible significance of these differences is discussed.
Nearly 10% of a sample of men charged with a variety of offences claimed amnesia for their offence. The amnesia occurred only among those who had committed violence and was most frequent following homicide. All the amnesics had a psychiatric disorder, four having a primary depressive illness and the remainder being almost equally divided between schizophrenia and alcohol abuse. None of the amnesias had any legal implications. The circumstances of the offences suggested a variety of mechanisms to account for the amnesia, including repression, dissociation and alcoholic black-outs. Psychological defence mechanisms were probably of some importance, even when alcohol was an important factor.
A battery of tests was developed to assess verbal, non-verbal and mixed cognitive functions. Interest was based on pattern of response rather than absolute scores. The subjects were 167 men held in prison on criminal charges or in a maximum security hospital after conviction. The present paper deals exclusively with two subgroups: the 61 schizophrenic men and the 41 men with no psychiatric disorder. The schizophrenic group as a whole presented a very different cognitive pattern from the ‘normal’ men. First, with the exception of the vocabulary subtest of the WAIS, the schizophrenics were inferior on all tests, whether verbal, non-verbal or mixed function. Secondly, they showed considerably more variation within subtests. The schizophrenic sample was therefore subdivided into four clinical groups. Each showed a distinctive cognitive profile. It is argued that these cognitive differences reflect real differences in the disorder and type of illness being experienced by members of these subgroups.
