Specialty choice in UK junior doctors: Is psychiatry the least popular specialty for UK and international medical graduates?

<p>Abstract</p> <p>Background</p> <p>In the UK and many other countries, many specialties have had longstanding problems with recruitment and have increasingly relied on international medical graduates to fill junior and senior posts. We aimed to determine what specialties were the most popular and desirable among candidates for training posts, and whether this differed by country of undergraduate training.</p> <p>Methods</p> <p>We conducted a database analysis of applications to Modernising Medical Careers for all training posts in England in 2008. Total number of applications (as an index of popularity) and applications per vacancy (as an index of desirability) were analysed for ten different specialties. We tested whether mean consultant incomes correlated with specialty choice.</p> <p>Results</p> <p>In, 2008, there were 80,949 applications for specialty training in England, of which 31,434 were UK graduates (39%). Among UK medical graduates, psychiatry was the sixth most popular specialty (999 applicants) out of 10 specialty groups, while it was fourth for international graduates (5,953 applicants). Among UK graduates, surgery (9.4 applicants per vacancy) and radiology (8.0) had the highest number of applicants per vacancy and paediatrics (1.2) and psychiatry (1.1) the lowest. Among international medical graduates, psychiatry had the fourth highest number of applicants per place (6.3). Specialty popularity for UK graduates was correlated with predicted income (p = 0.006).</p> <p>Conclusion</p> <p>Based on the number of applicants per place, there was some consistency in the most popular specialties for both UK and international medical graduates, but there were differences in the popularity of psychiatry. With anticipated decreases in the number of new international medical graduates training in the UK, university departments and professional associations may need to review strategies to attract more UK medical graduates into certain specialties, particularly psychiatry and paediatrics.</p

Risk assessment tools in criminal justice and forensic psychiatry: The need for better data

Violence risk assessment tools are increasingly used within criminal justice and forensic psychiatry, however there is little relevant, reliable and unbiased data regarding their predictive accuracy. We argue that such data are needed to (i) prevent excessive reliance on risk assessment scores, (ii) allow matching of different risk assessment tools to different contexts of application, (iii) protect against problematic forms of discrimination and stigmatisation, and (iv) ensure that contentious demographic variables are not prematurely removed from risk assessment tools

The association between psychiatric diagnosis and violent re-offending in adult offenders in the community.

BACKGROUND: High rates of repeat offending are common across nations that are socially and culturally different. Although psychiatric disorders are believed to be risk factors for violent reoffending, the available evidence is sparse and liable to bias. METHOD: We conducted a historical cohort study in Sweden of a selected sample of 4828 offenders given community sentences who were assessed by a psychiatrist during 1988-2001, and followed up for an average of 5 years for first violent offence, death, or emigration, using information from national registers. Hazard ratios for violent offending were calculated by Cox regression models. RESULTS: Nearly a third of the sample (n = 1506 or 31.3%) offended violently during follow-up (mean duration: 4.8 years). After adjustment for socio-demographic and criminal history variables, substance use disorders (hazard ratio 1.97, 95% CI, 1.40-2.77) and personality disorders (hazard ratio 1.71, 1.20-2.44) were significantly associated with an increased risk of violent offending. No other diagnoses were related to recidivism risk. Adding information on diagnoses of substance use and personality disorders to data recorded on age, sex, and criminal history improved only minimally the prediction of violent offending. CONCLUSION: Diagnoses of substance use and personality disorders are associated with the risk of subsequent violent offending in community offenders about as strongly as are its better documented demographic and criminal history risk factors. Despite this, assessment of such disorders in addition to demographic and criminal history factors enhances only minimally the prediction of violent offending in the community.RIGHTS : This article is licensed under the BioMed Central licence at http://www.biomedcentral.com/about/license which is similar to the 'Creative Commons Attribution Licence'. In brief you may : copy, distribute, and display the work; make derivative works; or make commercial use of the work - under the following conditions: the original author must be given credit; for any reuse or distribution, it must be made clear to others what the license terms of this work are

Assessing violence risk in first-episode psychosis: external validation, updating and net benefit of a prediction tool (OxMIV)

BACKGROUND: Violence perpetration is a key outcome to prevent for an important subgroup of individuals presenting to mental health services, including early intervention in psychosis (EIP) services. Needs and risks are typically assessed without structured methods, which could facilitate consistency and accuracy. Prediction tools, such as OxMIV (Oxford Mental Illness and Violence tool), could provide a structured risk stratification approach, but require external validation in clinical settings. OBJECTIVES: We aimed to validate and update OxMIV in first-episode psychosis and consider its benefit as a complement to clinical assessment. METHODS: A retrospective cohort of individuals assessed in two UK EIP services was included. Electronic health records were used to extract predictors and risk judgements made by assessing clinicians. Outcome data involved police and healthcare records for violence perpetration in the 12 months post-assessment. FINDINGS: Of 1145 individuals presenting to EIP services, 131 (11%) perpetrated violence during the 12 month follow-up. OxMIV showed good discrimination (area under the curve 0.75, 95% CI 0.71 to 0.80). Calibration-in-the-large was also good after updating the model constant. Using a 10% cut-off, sensitivity was 71% (95% CI 63% to 80%), specificity 66% (63% to 69%), positive predictive value 22% (19% to 24%) and negative predictive value 95% (93% to 96%). In contrast, clinical judgement sensitivity was 40% and specificity 89%. Decision curve analysis showed net benefit of OxMIV over comparison approaches. CONCLUSIONS: OxMIV performed well in this real-world validation, with improved sensitivity compared with unstructured assessments. CLINICAL IMPLICATIONS: Structured tools to assess violence risk, such as OxMIV, have potential in first-episode psychosis to support a stratified approach to allocating non-harmful interventions to individuals who may benefit from the largest absolute risk reduction

Examination of the psychometric properties of the FORensic oUtcome Measure (FORUM): a new outcome measure for forensic mental health services

INTRODUCTION: Forensic mental health services provide care to people in secure psychiatric hospitals and specialised community teams. Measuring outcomes is important to ensure such services perform optimally, however existing measures are not sufficiently comprehensive and are rarely patient reported. OBJECTIVES: To examine a novel instrument for measuring outcomes in forensic mental health services, the FORensic oUtsome Measure (FORUM), which consists of a complementary patient reported questionnaire (FORUM-P) and clinician reported questionnaire (FORUM-C). METHODS: Inpatients at a forensic psychiatric service based in a regional healthcare organization in the UK completed the FORUM-P, while members of their clinical teams completed the FORUM-C. Patients and clinicians also provided feedback on the questionnaires. RESULTS: Sixty-two patients participated with a mean age of 41.0 years (standard deviation 11.3). For internal consistency, Cronbach’s alpha for the FORUM-P was 0.87 (95% confidence interval (CI) 0.80-0.93) and for the FORUM-C was 0.93 (95% CI 0.91-0.96). For test-retest reliability the weighted kappa for the FORUM-P was 0.44 (95% CI 0.24-0.63) and for the FORUM-C was 0.78 (95% CI 0.73-0.85). For interrater reliability of the FORUM-C the Spearman correlation coefficient was 0.47 (95% CI 0.18-0.69). The FORUM-P received an average rating of 4.0 out of 5 for comprehensiveness, 4.6 for ease of use and 3.9 for relevance, while the FORUM-C received 4.1 for comprehensiveness, 4.5 for ease of use and 4.3 for relevance. CONCLUSIONS: Outcome measures in forensic mental health can be developed with good measures of reliability and validity, and can be introduced into services to monitor patient progress. DISCLOSURE: No significant relationships

Risk factors for self-harm in prison : a systematic review and meta-analysis

Background: Self-harm is a leading cause of morbidity in prisoners. Although a wide range of risk factors for self-harm in prisoners has been identified, the strength and consistency of effect sizes is uncertain. We aimed to synthesise evidence and assess the risk factors associated with self-harm inside prison. Methods: In this systematic review and meta-analysis, we searched four electronic databases (PubMed, Embase, Web of Science, and PsycINFO) for observational studies on risk factors for self-harm in prisoners published from database inception to Oct 31, 2019, supplemented through correspondence with authors of studies. We included primary studies involving adults sampled from general prison populations who self-harmed in prison and a comparison group without self-harm in prison. We excluded studies with qualitative or ecological designs, those that reported on lifetime measures of self-harm or on selected samples of prisoners, and those with a comparison group that was not appropriate or not based on general prison populations. Data were extracted from the articles and requested from study authors. Our primary outcome was the risk of self-harm for risk factors in prisoners. We pooled effect sizes as odds ratios (OR) using random effects models for each risk factor examined in at least three distinct samples. We assessed study quality on the basis of the Newcastle-Ottawa Scale and examined between-study heterogeneity. The study protocol was registered with PROSPERO, CRD42018087915. Findings: We identified 35 independent studies from 20 countries comprising a total of 663 735 prisoners, of whom 24 978 (3.8%) had self-harmed in prison. Across the 40 risk factors examined, the strongest associations with self-harm in prison were found for suicide-related antecedents, including current or recent suicidal ideation (OR 13.8, 95% CI 8.6–22.1; I2=49%), lifetime history of suicidal ideation (8.9, 6.1–13.0; I2=56%), and previous self-harm (6.6, 5.3–8.3; I2=55%). Any current psychiatric diagnosis was also strongly associated with self-harm (8.1, 7.0–9.4; I2=0%), particularly major depression (9.3, 2.9–29.5; I2=91%) and borderline personality disorder (9.2, 3.7–22.5; I2=81%). Prison-specific environmental risk factors for self-harm included solitary confinement (5.6, 2.7–11.6; I2=98%), disciplinary infractions (3.5, 1.2–9.7; I2=99%), and experiencing sexual or physical victimisation while in prison (3.2, 2.1–4.8; I2=44%). Sociodemographic (OR range 1.5–2.5) and criminological (1.8–2.3) factors were only modestly associated with self-harm in prison. We did not find clear evidence of publication bias. Interpretation: The wide range of risk factors across clinical and custody-related domains underscores the need for a comprehensive, prison-wide approach towards preventing self-harm in prison. This approach should incorporate both population and targeted strategies, with multiagency collaboration between the services for mental health, social care, and criminal justice having a key role

Psychiatric disorders and reoffending risk in individuals with community sentences in Sweden: a national cohort study

Background: Community sentences are widely used in many countries, often comprising the majority of criminal justice sanctions. Psychiatric disorders are highly prevalent in community-sentenced populations and are thus potential targets for treatment interventions designed to reduce reoffending. We examined the association between psychiatric disorders and reoffending in a national cohort of individuals given community sentences in Sweden, with use of a sibling control design to account for unmeasured familial confounding. Methods: We did a longitudinal cohort study of 82 415 individuals given community sentences between Nov 1, 1991, and Dec 31, 2013, in Sweden using data from population-based registers. We calculated hazard ratios (HRs) for any reoffending and violent reoffending with Cox regression models. We compared community-sentenced siblings with and without psychiatric disorders to control for potential familial confounding. Additionally, we calculated population attributable fractions to assess the contribution of psychiatric disorders to reoffending behaviours. The primary outcomes of the study were any (general) reoffending and violent reoffending. Findings: Between Nov 1, 1991, and Dec 31, 2013, those given community sentences who were diagnosed with any psychiatric disorder had an increased reoffending risk in men (adjusted HR 1·59, 95% CI 1·56–1·63 for any reoffending; 1·60, 1·54–1·66 for violent reoffending) and women (1·71, 1·61–1·82 for any reoffending; 2·19, 1·88–2·54 for violent reoffending). Risk estimates remained elevated after adjustment for familial confounding. Schizophrenia spectrum disorders, personality disorders, and substance use disorders had stronger associations with violent reoffending than did other psychiatric disorders. Assuming causality, the adjusted population attributable risk of psychiatric disorders on violent reoffending was 8·3% (95% CI 6·6–10·0) in the first 2 years of community follow-up in men and 30·9% (22·7–39·0) in women. Interpretation: Psychiatric disorders were associated with an increased risk of any reoffending and violent reoffending in the community-sentenced population. The magnitude of the association between psychiatric disorders and reoffending varied by individual diagnosis. Substance use disorders had the highest absolute and relative risks. Most of the increased risk for any reoffending in individuals with psychiatric disorders could be attributed to comorbid substance misuse. Given their high prevalence, substance use disorders should be the focus of treatment programmes in community-sentenced populations

Depression and violence: a Swedish population study.

BACKGROUND: Depression increases the risk of a range of adverse outcomes including suicide, premature mortality, and self-harm, but associations with violent crime remain uncertain. We aimed to determine the risks of violent crime in patients with depression and to investigate the association between depressive symptoms and violent crime in a cohort of twins. METHODS: We conducted two studies. The first was a total population study in Sweden of patients with outpatient diagnoses of depressive disorders (n=47,158) between 2001 and 2009 and no lifetime inpatient episodes. Patients were age and sex matched to general population controls (n=898,454) and risk of violent crime was calculated. Additionally, we compared the odds of violent crime in unaffected half-siblings (n=15,534) and full siblings (n=33,516) of patients with the general population controls. In sensitivity analyses, we examined the contribution of substance abuse, sociodemographic factors, and previous criminality. In the second study, we studied a general population sample of twins (n=23,020) with continuous measures of depressive symptoms for risk of violent crime. FINDINGS: During a mean follow-up period of 3·2 years, 641 (3·7%) of the depressed men and 152 (0·5%) of the depressed women violently offended after diagnosis. After adjustment for sociodemographic confounders, the odds ratio of violent crime was 3·0 (95% CI 2·8–3·3) compared with the general population controls. The odds of violent crime in half-siblings (adjusted odds ratio 1·2 [95% CI 1·1–1·4]) and full siblings (1·5, 95% CI 1·3–1·6) were significantly increased, showing some familial confounding of the association between depression and violence. However, the odds increase remained significant in individuals with depression after adjustment for familial confounding, and in those without substance abuse comorbidity or a previous violent conviction (all p<0·0001). In the twin study, during the mean follow-up time of 5·4 years, 88 violent crimes were recorded. Depressive symptoms were associated with increased risk of violent crime and a sensitivity analysis identified little difference in risk estimate when all crimes (violent and non-violent) was the outcome. INTERPRETATION: Risk of violent crime was increased in individuals with depression after adjustment for familial, sociodemographic and individual factors in two longitudinal studies. Clinical guidelines should consider recommending violence risk assessment in certain subgroups with depression.The Wellcome TrustThe Swedish Research CouncilPublishe

Risk of Subjection to Violence and Perpetration of Violence in Persons With Psychiatric Disorders in Sweden

Importance Key outcomes for persons with psychiatric disorders include subjection to violence and perpetration of violence. The occurrence of these outcomes and their associations with psychiatric disorders need to be clarified. Objective To estimate the associations of a wide range of psychiatric disorders with the risks of subjection to violence and perpetration of violence. Design, Setting, and Participants A total of 250 419 individuals born between January 1, 1973, and December 31, 1993, were identified to have psychiatric disorders using Swedish nationwide registers. Premorbid subjection to violence was measured since birth. The patients were matched by age and sex to individuals in the general population (n = 2504 190) and to their full biological siblings without psychiatric disorders (n = 194 788). The start date for the patients and control groups was defined as the discharge date of the first psychiatric episode. The participants were censored either when they migrated, died, experienced the outcome of interest, or reached the end of the study period on December 31, 2013. Data were analyzed from January 15 to September 14, 2019. Exposures Patients with common psychiatric disorders (eg, schizophrenia, bipolar disorder, depression, and anxiety) were differentiated using a hierarchical approach. Patients with personality disorders and substance use disorders were also included. Main Outcomes and Measures Subjection to violence was defined as an outpatient visit (excluding a primary care visit), inpatient episode, or death associated with any diagnosis of an injury that was purposefully inflicted by other persons. Perpetration of violence was defined as a violent crime conviction. Stratified Cox regression models were fitted to account for the time at risk, a range of sociodemographic factors, a history of violence, and unmeasured familial confounders (via sibling comparisons). Results Among 250 419 patients (55.4% women), the median (interquartile range) age at first diagnosis ranged from 20.0 (17.4-24.0) years for alcohol use disorder to 23.7 (19.9-28.8) years for anxiety disorder. Compared with 2504 190 matched individuals without psychiatric disorders from the general population, patients with psychiatric disorders were more likely to be subjected to violence (7.1 [95% CI, 6.9-7.2] vs 1.0 [95% CI, 0.9-1.0] per 1000 person-years) and to perpetrate violence (7.5 [95% CI, 7.4-7.6] vs 0.7 [95% CI, 0.7-0.7] per 1000 person-years). In the fully adjusted models, patients with psychiatric disorders were 3 to 4 times more likely than their siblings without psychiatric disorders to be either subjected to violence (adjusted hazard ratio [aHR], 3.4 [95% CI, 3.2-3.6]) or to perpetrate violence (aHR, 4.2 [95% CI, 3.9-4.4]). Diagnosis with any of the specific disorders was associated with higher rates of violent outcomes, with the sole exception of schizophrenia, which was not associated with the risk of subjection to violence. Conclusions and Relevance In this study, persons with psychiatric disorders were 3 to 4 times more likely than their siblings without psychiatric disorders to have been subjected to violence or to have perpetrated violence after the onset of their conditions. The risks of both outcomes varied by specific psychiatric diagnosis, history of violence, and familial risks. Clinical interventions may benefit from targeted approaches for the assessment and management of risk of violence in people with psychiatric disorders.Peer reviewe

Structural brain correlates of interpersonal violence: systematic review and voxel-based meta-analysis of neuroimaging studies

Owing to inconsistent nomenclature and results, we have undertaken a label-based review and anatomical likelihood estimation (ALE) meta-analysis of studies measuring the quantitative association between regional grey matter (GM) volume and interpersonal violence. Following PRISMA guidelines, we identified studies by searching 3 online databases (Embase, Medline, PsycInfo) and reference lists. Thirty-five studies were included in the label-based review, providing information for 1288 participants and 86 brain regions. Per region, 0–57% of the results indicated significant reductions in GM volume, while 0–23% indicated significant increases. The only region for which more than half of all results indicated significant reductions was the parietal lobe. However, these results were dispersed across subregions. The ALE meta-analysis, which included 6 whole-brain voxel-based morphometry studies totaling 278 participants and reporting 144 foci, showed no significant clusters of reduced GM volume. No material differences were observed when excluding experiments using reactive violence as outcome or subjects diagnosed with psychopathy. Possible explanations for these findings are phenomenological and etiological heterogeneity, and insufficient power in the label-based review and ALE metaanalysis to detect small effects. We recommend that future studies distinguish between subtypes of interpersonal violence, and investigate mediation by underlying emotional and cognitive processes