Terrorism, radicalisation, extremism, authoritarianism and fundamentalism: A systematic review of the quality and psychometric properties of assessments

Background   Currently, terrorism and suicide bombing are global psychosocial processes that attracts a growing number of psychological and psychiatric contributions to enhance practical counter-terrorism measures. The present study is a systematic review that explores the methodological quality reporting and the psychometric soundness of the instruments developed to identify risk factors of terrorism, extremism, radicalisation, authoritarianism and fundamentalism.  Method   A systematic search strategy was established to identify instruments and studies developed to screen individuals at risk of committing extremist or terrorist offences using 20 different databases across the fields of law, medicine, psychology, sociology and politics. Information extracted was consolidated into two different tables and a 26-item checklist, reporting respectively background information, the psychometric properties of each tool, and the methodological quality markers of these tools. 37 articles met our criteria, which included a total of 4 instruments to be used operationally by professionals, 17 tools developed as research measures, and 9 inventories that have not been generated from a study.  Results   Just over half of the methodological quality markers required for a transparent methodological description of the instruments were reported. The amount of reported psychological properties was even fewer, with only a third of them available across the different studies. The category presenting the least satisfactory results was that containing the 4 instruments to be used operationally by professionals, which can be explained by the fact that half of them refrained from publishing the major part of their findings and relevant guidelines.  Conclusions  A great number of flaws have been identified through this systematic review. The authors encourage future researchers to be more thorough, comprehensive and transparent in their methodology. They also recommend the creation of a multi-disciplinary joint working group in order to best tackle this growing contemporary problem

Mentally disordered young offenders in transition from child and adolescent to adult mental health services across England and Wales

This paper provides an overview of transitions across forensic child and adolescent mental health services in England and Wales. The aim of this paper is to delineate the national secure services system for young people in contact with the youth justice system. This paper reviews findings from the existing literature of transitions across forensic child and adolescent mental health services, drawing attention to present facilitators and barriers to optimal transition. We examine the infrastructure of current services and highlight gaps between child and adult service continuity and evaluate the impact of poor transitions on young offenders’ mental health and wellbeing. Young offenders experience a broad range of difficulties, from the multiple interfaces with the legal system, untreated mental health problems, and poor transition to adult services. Barriers such as long waiting lists, lack of coordination between services and lack of transition preparation impede significantly smooth transitions. We need to develop, test and evaluate models of transitional care that improve mental health and wellbeing of this group. Mapping young offenders’ care pathway will help to understand their needs and also to impact current policy and practice. Key workers in forensic services should facilitate the transition process by developing sustainable relationships with the young person and creating a safe clinical environment. Transition of care from forensic child and adolescent mental health services is a neglected area. This paper attempts to highlight the nature and magnitude of the problems at the transition interface in a forensic context

Risperidone (depot) for schizophrenia

Background: Risperidone is the first new generation antipsychotic drug made available in a long-acting injection formulation. Objectives To examine the effects of depot risperidone for treatment of schizophrenia or related psychoses in comparison with placebo, no treatment or other antipsychotic medication. To critically appraise and summarise current evidence on the resource use, cost and cost-effectiveness of risperidone (depot) for schizophrenia. Search methods: We searched the Cochrane Schizophrenia Group's Register (December 2002, 2012, and October 28, 2015). We also checked the references of all included studies, and contacted industry and authors of included studies. Selection criteria: Randomised clinical trials comparing depot risperidone with other treatments for people with schizophrenia and/or schizophrenia-like psychoses. Data collection and analysis: Two review authors independently selected trials, assessed trial quality and extracted data. For dichotomous data, we calculated the risk ratio (RR), with 95% confidence interval (CI). For continuous data, we calculated mean differences (MD). We assessed risk of bias for included studies and created 'Summary of findings' tables using GRADE. Main results: Twelve studies, with a total of 5723 participants were randomised to the following comparison treatments: Risperidone depot versus placebo Outcomes of relapse and improvement in mental state were neither measured or reported. In terms of other primary outcomes, more people receiving placebo left the study early by 12 weeks (1 RCT, n=400, RR 0.74 95% CI 0.63 to 0.88, very low quality evidence), experienced severe adverse events in short term (1 RCT, n=400, RR 0.59 95% CI 0.38 to 0.93, very low quality evidence). There was however, no difference in levels of weight gain between groups (1 RCT, n=400, RR 2.11 95% CI 0.48 to 9.18, very low quality evidence). Risperidone depot versus general oral antipsychotics The outcome of improvement in mental state was not presented due to high levels of attrition, nor were levels of severe adverse events explicitly reported. Most primary outcomes of interest showed no difference between treatment groups. However, more people receiving depot risperidone experienced nervous system disorders (long-term:1 RCT, n=369, RR 1.34 95% CI 1.13 to 1.58, very-low quality evidence). Risperidone depot versus oral risperidone Data for relapse and severe adverse events were not reported. All outcomes of interest were rated as moderate quality evidence. Main results showed no differences between treatment groups with equivocal data for change in mental state, numbers leaving the study early, any extrapyramidal symptoms, weight increase and prolactin-related adverse events. Risperidone depot versus oral quetiapine Relapse rates and improvement in mental state were not reported. Fewer people receiving risperidone depot left the study early (long-term: 1 RCT, n=666, RR 0.84 95% CI 0.74 to 0.95, moderate quality evidence). Experience of serious adverse events was similar between groups (low quality evidence), but more people receiving depot risperidone experienced EPS (1 RCT, n=666, RR 1.83 95% CI 1.07 to 3.15, low quality evidence), had greater weight gain (1 RCT, n=666, RR 1.25 95% CI 0.25 to 2.25, low quality evidence) and more prolactin-related adverse events (1 RCT, n=666, RR 3.07 95% CI 1.13 to 8.36, very low quality evidence). Risperidone depot versus oral aripiprazole Relapse rates, mental state using PANSS, leaving the study early, serious adverse events and weight increase were similar between groups. However more people receiving depot risperidone experienced prolactin-related adverse events compared to those receiving oral aripiprazole (2 RCTs, n=729, RR 9.91 95% CI 2.78 to 35.29, very low quality of evidence). Risperidone depot versus oral olanzapine Relapse rates were not reported in any of the included studies for this comparison. Improvement in mental state using PANSS and instances of severe adverse events were similar between groups. More people receiving depot risperidone left the study early than those receiving oral olanzapine (1 RCT, n=618, RR 1.32 95% CI 1.10 to 1.58, low quality evidence) with those receiving risperidone depot also experiencing more extrapyramidal symptoms (1 RCT, n=547, RR 1.67 95% CI 1.19 to 2.36, low quality evidence). However, more people receiving oral olanzapine experienced weight increase (1 RCT, n=547, RR 0.56 95% CI 0.42 to 0.75, low quality evidence). Risperidone depot versus atypical depot antipsychotics (specifically paliperidone palmitate) Relapse rates were not reported and rates of response using PANSS, weight increase, prolactin-related adverse events and glucose-related adverse events were similar between groups. Fewer people left the study early due to lack of efficacy from the risperidone depot group (long term: 1 RCT, n=749, RR 0.60 95% CI 0.45 to 0.81, low quality evidence), but more people receiving depot risperidone required use of EPS-medication (2 RCTs, n=1666, RR 1.46 95% CI 1.18 to 1.8, moderate quality evidence). Risperidone depot versus typical depot antipsychotics Outcomes of relapse, severe adverse events or movement disorders were not reported. Outcomes relating to improvement in mental state demonstrated no difference between groups (low quality evidence). However, more people receiving depot risperidone compared to other typical depots left the study early (long-term:1 RCT, n=62, RR 3.05 95% CI 1.12 to 8.31, low quality evidence). Authors' conclusions: Depot risperidone may be more acceptable than placebo injection but it is hard to know if it is any more effective in controlling the symptoms of schizophrenia. The active drug, especially higher doses, may be associated with more movement disorders than placebo. People already stabilised on oral risperidone may continue to maintain benefit if treated with depot risperidone and avoid the need to take tablets, at least in the short term. In people who are happy to take oral medication the depot risperidone is approximately equal to oral risperidone. It is possible that the depot formulation, however, can bring a second-generation antipsychotic to people who do not reliably adhere to treatment. People with schizophrenia who have difficulty adhering to treatment, however, are unlikely to volunteer for a clinical trial. Such people may gain benefit from the depot risperidone with no increased risk of extrapyramidal side effects

Long-stay in forensic-psychiatric care in the UK

Purpose Forensic services provide care for mentally disordered offenders. In England this is provided at three levels of security—low, medium and high. Significant number of patients within these settings remain detained for protracted periods of time. This is both very costly and restrictive for individuals. No national studies have been conducted on this subject in England. Methods We employed a cross-sectional design using anonymised data from medical records departments in English secure forensic units. Data were collected from a large sample of medium secure patients (n = 1572) as well as the total high secure patient population (n = 715) resident on the census date (01-04-2013). We defined long-stay as a stay of more than 10 years in high, 5 years in medium or 15 years in a mix of high and medium secure settings. Long-stay status was assessed against patient demographic and admission information. Results We identified a significant proportion of long-stayers: 23.5% in high secure and 18.1% in medium secure care. Amongst medium secure units a large variation in long-stay prevalence was observed from 0 to 50%. Results indicated that MHA section, admission source and current ward type were independent factors associated with long-stay status. Conclusion This study identified a significant proportion of long-stayers in forensic settings in England. Sociodemographic factors identified in studies in individual settings may be less important than previously thought. The large variation in prevalence of long-stayers observed in the medium secure sample warrants further investigation

The Forensic Restrictiveness Questionnaire : development, validation and revision

Introduction: Forensic psychiatric care is often practiced in closed institutions. These highly regulated, secure, and prescriptive environments arguably reduce patient autonomy, self-expression, and personhood. Taken together these settings are restrictive as patients’ active participation in clinical, organizational, community, and personal life-worlds are curtailed. The consequences of patients’ experiences of restrictiveness have not been explored empirically. This study aimed to develop a psychometrically-valid measure of experiences of restrictiveness. This paper presents the development, validation, and revision of the Forensic Restrictiveness Questionnaire (FRQ). Methods: In total, 235 patients recruited from low, medium, and high secure hospitals across England completed the FRQ. The dimensionality of the 56-item FRQ was tested using Principle Axis Factor Analysis and parallel analysis. Internal consistency was explored with Cronbach’s α. Ward climate (EssenCES) and quality of life (FQL-SV) questionnaires were completed by participants as indicators of convergent validity. Exploratory Factor Analysis (EFA) and Cronbach’s α guided the removal of items that did not scale adequately. Results: The analysis indicated good psychometric properties. EFA revealed a unidimensional structure, suggesting a single latent factor. Convergent validity was confirmed as the FRQ was significantly negatively correlated with quality of life (Spearman’s ρ = −0.72) and ward climate (Spearman’s ρ = −0.61). Internal consistency was strong (α = 0.93). Forty-one items were removed from the pilot FRQ. The data indicate that a final 15-item FRQ is a valid and internally reliable measure. Conclusion: The FRQ offers a novel and helpful method for clinicians and researchers to measure and explore forensic patients’ experiences of restrictiveness within secure hospitals

Prevalence of mental disorders and symptoms among incarcerated youth : a meta-analysis of 30 studies

Incarcerated youth have high levels of mental disorders. However, there are no up-to-date reviews examining the prevalence rates of a broad range of mental disorders and symptoms across youth justice populations. The current review aims to bridge this gap. We conducted a systematic search of the literature using PsycINFO, Medline, Embase, and Web of Science databases. We used meta-analyses to produce pooled prevalence figures for each mental health disorder and symptoms, and meta-regression to test for the moderating effects of covariates, such as gender. Thirty studies were included involving 8,153 participants. Meta- regression analysis showed that females had higher prevalence rates for depression, separ- ation anxiety disorder and suicide. Males had higher prevalence rates for conduct disorder and emerging antisocial personality disorder. Emerging personality disorders (borderline per- sonality disorder: 21%; 95% CI: 13–28%; antisocial personality disorder: 62%; 95% CI: 39–82%) were relatively common in both genders. The findings of this meta-analysis show the need for robust mental health services in custody settings. Adopting a developmentally focused approach would increase understanding of incarcerated youths’ needs and help to early detection of emerging personality symptoms. To improve young people’s mental health, we need to ensure that services do not misidentify young people’s needs due to diagnostic limitations

Mapping transitional care-pathways among young people discharged from adolescent forensic medium secure units in England

This study tracked young offenders transitioning from national adolescent forensic medium secure units to adult services in the UK within a six-month period. We used a mapping exercise to identify eligible participants moving during the study period from all national adolescent forensic medium secure units in England. Young people older than 17.5 years or those who had turned 18 years (transition boundary) and had been referred to adult and community services were included. Of the 34 patients identified, 53% moved to forensic adult inpatient services. Psychosis was the most prevalent symptom among males (29%), and emerging personality disorder symptomatology was commonly reported among females (18%) followed by learning disability (24%). The mean time for transition to adult mental-health services and community settings was eight months. There were no shared transition or discharge policies, and only two hospitals had discharge guidelines. The findings highlight the need for consistency between policy and practice among services along with the development of individualised care pathways. Future qualitative research is needed to understand and reflect on young people’s and carers’ experiences to improve transition service delivery

People with severe problematic personality traits and offending histories: What influences occupational participation?

Background: Occupational participation is important for personality disordered offenders (PDOs) becauseit is integral to health and desistance from offending. What influences occupational participation isunknown for PDOs in the community, limiting effective intervention to affect change. In England andWales, the Offender Personality Disorder Pathway aims to improve outcomes for people consideredhighly likely to have a severe personality disorder and who present a high risk of reoffending, who aredetermined to be PDOs on the basis of a structured assessment. This study identified the influencers ofoccupational participation for the population who receive this service.Method: In this critical realist, qualitative study, narrative interviews were conducted with 18 PDOssupervised by probation in England. Transcripts were analyzed using a grounded theory approach toestablish influencers of occupational participation.Results: Four themes describe influencers of occupational participation: function of occupations;influence of the past; external forces; and learning and adaptation. The latter theme reflectedunderstandings of occupational adaptation described by the Model of Human Occupation.Conclusions: An intervention to increase prosocial occupational participation should be developed andevaluated for PDOs in the community, taking account of occupational participation over the life course

The forensic restrictiveness questionnaire: development, validation, and revision

Introduction: Forensic psychiatric care is often practiced in closed institutions. These highly regulated, secure, and prescriptive environments arguably reduce patient autonomy, self-expression, and personhood. Taken together these settings are restrictive as patients’ active participation in clinical, organizational, community, and personal life-worlds are curtailed. The consequences of patients’ experiences of restrictiveness have not been explored empirically. This study aimed to develop a psychometrically-valid measure of experiences of restrictiveness. This paper presents the development, validation, and revision of the Forensic Restrictiveness Questionnaire (FRQ). Methods: In total, 235 patients recruited from low, medium, and high secure hospitals across England completed the FRQ. The dimensionality of the 56-item FRQ was tested using Principle Axis Factor Analysis and parallel analysis. Internal consistency was explored with Cronbach’s α. Ward climate (EssenCES) and quality of life (FQL-SV) questionnaires were completed by participants as indicators of convergent validity. Exploratory Factor Analysis (EFA) and Cronbach’s α guided the removal of items that did not scale adequately. Results: The analysis indicated good psychometric properties. EFA revealed a unidimensional structure, suggesting a single latent factor. Convergent validity was confirmed as the FRQ was significantly negatively correlated with quality of life (Spearman’s ρ = −0.72) and ward climate (Spearman’s ρ = −0.61). Internal consistency was strong (α = 0.93). Forty-one items were removed from the pilot FRQ. The data indicate that a final 15-item FRQ is a valid and internally reliable measure. Conclusion: The FRQ offers a novel and helpful method for clinicians and researchers to measure and explore forensic patients’ experiences of restrictiveness within secure hospitals