Experiences and perceptions of nursing staff working with long-stay patients in a high secure psychiatric hospital setting

Background and Objective: Forensic psychiatric nursing is a demanding nursing specialty that deals with a highly complex group of patients who are detained in restrictive environments, often for lengthy periods. There is little information about the daily experiences of these nurses. This study sought to explore the roles and relationships of forensic psychiatric nurses with long-stay patients in a high secure hospital in England. Method and Analysis: The study obtained data via three focus groups, and thematic analysis was carried out using NVIVO 10 software. Results: Five prominent themes emerged: First, nurses elaborated on their roles with patients and the kinds of interactions they had with them. The next two themes explored the reasons why some patients are long-stay patients and the challenges nurses face while working with this group. The fourth theme was the impact of external support, such as the patient’s families, on length of stay. The final theme covered the changes that the nurses observed in these patients and in themselves over time. Conclusion: It was noticeable that those interviewed were committed professionals, eager to provide an optimistic and hopeful environment for the patients to help them progress through “the system”. The study presents a number of pertinent issues regarding long-stay patients that provide a basis for further research and to inform policy, educational reforms, and clinical practice

Volunteering with sex offenders: the attitudes of volunteers toward sex offenders, their treatment and rehabilitation

The general public has been shown to hold negative attitudes toward sexual offenders (Levenson, Brannon, Fortney, & Baker, 2007; Willis et al., 2010), sex offender treatment (e.g. Olver & Barlow, 2010) and the rehabilitation of sexual offenders (Payne, Tewksbury, & Mustaine, 2010). It appears pertinent to the success of sex offender management strategies that utilise volunteers that selected volunteers do not share these attitudes. Here, volunteers for Circles of Support and Accountability (CoSA), a community-based initiative supporting the reintegration of sex offenders, completed three validated psychometric measures assessing attitudes toward sex offenders in general and toward their treatment and rehabilitation. Responses were compared to a UK general public sample. The results showed that volunteers held more positive attitudes toward sex offenders, sex offender treatment and sex offender rehabilitation than the UK general public sample. The significance of these findings is discussed alongside directions for future research

Inpatient forensic-psychiatric care: legal frameworks and service provision in three European countries

Laws governing the detention and treatment of mentally disordered offenders (MDOs) vary widely across Europe, yet little information is available about the features of these laws and their comparative advantages and disadvantages. The purpose of this article is to compare the legal framework governing detention in forensic psychiatric care in three European countries with long established services for MDOs, England, Germany and the Netherlands. A literature review was conducted alongside consultation with experts from each country. We found that the three countries differ in several areas, including criteria for admission, review of detention, discharge process, the concept of criminal responsibility, service provision and treatment philosophy. Our findings suggest a profound difference in how each country relates to MDOs, with each approach contributing to different pathways and potentially different outcomes for the individual. Hopefully making these comparisons will stimulate debate and knowledge exchange on an international level to aid future research and the development of best practice in managing this population

Oxytocin Affects the Connectivity of the Precuneus and the Amygdala: A Randomized, Double-Blinded, Placebo-Controlled Neuroimaging Trial

BACKGROUND: Although oxytocin is one of the most widely studied neuropeptides in recent times, the mechanistic process by which it modulates social-affective behavior in the brain is not yet clearly understood. Thus, to understand the neurophysiological basis of oxytocin effects, we used resting-state functional MRI to examine the effects of intranasal oxytocin on brain connectivity in healthy males. METHODS: Using a randomized, double-blinded, placebo-controlled, crossover design, 15 healthy male volunteers received 24 IU intranasal oxytocin or placebo prior to resting-state functional MRI acquisition at 3T. RESULTS: We found that oxytocin significantly reduced the degree centrality of the right precuneus (P<.05). Oxytocin also reduced connectivity between the bilateral amygdalae and between the right precuneus and the right and left amygdala (P<.05). Although there were no significant changes in regional homogeneity at the whole brain level, posthoc results showed a reduction involving the right precuneus (P<.05). CONCLUSIONS: These results show that oxytocin affects one of the key centers in the brain for social cognition and introspective processing, the precuneus, and enhances our understanding of how oxytocin can modulate brain networks at rest. An improved understanding of the neurophysiological effects of oxytocin can be important in terms of evaluating the mechanisms that are likely to underlie the clinical responses observed upon long-term oxytocin administration

English vs. Dutch high secure hospitals: service user perspectives

Purpose: The aim of this paper is to describe service users’ perspectives on the difference between high secure long-stay forensic psychiatric services in the Netherlands and high secure forensic psychiatric care in England. These perspectives are relevant in considering the benefits of a similar long-stay service in England. Method: A current in-patient detained in a high secure hospital in England and other mental health service users and carers with experience in forensic-psychiatric settings were asked to watch a documentary on a Dutch high secure long-stay service. Then they were invited to make comparisons between this service and high-secure care in England. These perspectives were gained in the context of their membership of the Service User Reference Group of an externally funded study on long-stay in forensic-psychiatric settings in England. Findings: Our small group of participants highlighted the importance of relational security, meaningful occupation, autonomy, positive therapeutic relationships with staff and a homely environment for those with lengthy admissions and perceived these to be better met in the Dutch service. These factors might contribute to improved quality of life that services should strive to achieve, especially for those with prolonged admissions. Practical Implications: Perspectives of service users with lived experience of long-stay in forensic settings are important in informing service developments. Lessons can be learnt from initiatives to improve the quality of life of long-stay services in other countries and consideration be given on how to best manage this unique group. Originality/Value: To our knowledge this is the first study asking service users about their view on forensic services in other countries. Our findings suggest that service users have valuable contributions to make to aid service developments and should be involved in similar such exercises in the future

The characteristics and needs of older forensic psychiatric patients: a cross-sectional study in secure units within one UK regional service

Although the number of older patients in forensic psychiatric settings is increasing, there is limited information around their sociodemographic characteristics, needs and cognitive abilities. This cross-sectional study focuses on patients aged ≥50 years in three (high, medium and low) secure forensic psychiatric services in England. The study comprises: 1. Analysis of sociodemographic characteristics of all patients (n = 94) in the services; 2. Analysis of the clinical notes and administration of needs and cognitive assessments to a subsample of patients (n = 41). The main outcomes include: sociodemographic characteristics, data on residency, risk, violence, mental and physical health, cognitive ability and individual needs. Data analysis is carried out through descriptive tests and correlation and inferential analyses of outcomes. Results evidence that most patients are White-British single males aged 50–54 years and 88% have at least one physical health condition. A quarter of the patients has cognitive impairment. The most common psychiatric disorder is Personality Disorder (60%); comorbid psychiatric disorders are prevalent (54%). Length of stay averages 6+ years and is longest in high security. Patients’ needs are mostly met. The least met needs are social opportunities. Future comparative research against younger populations could give better context to research findings from this study

Ageing in forensic psychiatric secure settings: the voice of older patients

Older patients account for around 20% of the population in secure forensic psychiatric services in the UK. However, little qualitative research has investigated the experience of ageing in secure settings. This study aimed to gather the individual views of a sample of patients over 50 years old in the UK at different levels of security. Fifteen participants were selected and underwent one-on-one qualitative interviews. The interviews were analysed through thematic analysis, which generated seven themes: Self-agency, activities, social life, practical matters, recovery, physical health and service improvement. Study findings highlighted the complexity of ageing in secure settings. Despite the positive feedback reported in aspects such as physical health care, education opportunities, staff and support of religious practices, participants experienced added barriers to recovery, caused by social isolation/withdrawal and activities/treatment that did not respond to their complex age-related needs, generating poor motivation to engage. Our findings call for the development/implementation of programmes tailored to the unique needs of older patients. This process requires an active involvement of the primary stakeholders and further patient-centred research

Clozapine dose for schizophrenia

Background: Schizophrenia and related disorders such as schizophreniform and schizoaffective disorder are serious mental illnesses characterised by profound disruptions in thinking and speech, emotional processes, behaviour and sense of self. Clozapine is useful in the treatment of schizophrenia and related disorders, particularly when other antipsychotic medications have failed. It improves positive symptoms (such as delusions and hallucinations) and negative symptoms (such as withdrawal and poverty of speech). However, it is unclear what dose of clozapine is most effective with the least side effects. Objectives: To compare the efficacy and tolerability of clozapine at different doses and to identify the optimal dose of clozapine in the treatment of schizophrenia, schizophreniform and schizoaffective disorders. Search methods: We searched the Cochrane Schizophrenia Group’s Study-Based Register of Trials (August 2011 and 8 December 2016). Selection criteria: All relevant randomised controlled trials (RCTs), irrespective of blinding status or language, that compared the effects of clozapine at different doses in people with schizophrenia and related disorders, diagnosed by any criteria. Data collection and analysis: We independently inspected citations from the searches, identified relevant abstracts, obtained full articles of relevant abstracts, and classified trials as included or excluded. We included trials that met our inclusion criteria and reported useable data. For dichotomous data, we calculated the relative risk (RR) and the 95% confidence interval (CI) on an intention-to-treat basis based on a random-effects model. For continuous data, we calculated mean differences (MD) again based on a random-effects model. We assessed risk of bias for included studies and created ’Summary of findings’ tables using GRADE. Main results: We identified five studies that could be included. Each compared the effects of clozapine at very low dose (up to 149 mg/day), low dose (150 mg/day to 300 mg/day) and standard dose (301 mg/day to 600 mg/day). Four of the five included studies were based on a small number of participants. We rated all the evidence reported for the main outcomes of interest as low or very low quality. No data were available for the main outcomes of global state, service use or quality of life. Very low dose compared to low dose: We found no evidence of effect on mental state between low and very low doses of clozapine in terms of average Brief Psychiatric Rating Scale-Anchored (BPRS-A) endpoint score (1 RCT, n = 31, MD 3.55, 95% CI −4.50 to 11.60, very low quality evidence). One study found no difference between groups in body mass index (BMI) in the short term (1 RCT, n = 59, MD −0.10, 95% CI −0.95 to 0.75, low-quality evidence). Very low dose compared to standard dose: We found no evidence of effect on mental state between very low doses and standard doses of clozapine in terms of average BPRS-A endpoint score (1 RCT, n = 31,MD 6.67, 95%CI −2.09 to 15.43, very low quality evidence). One study found no difference between groups in BMI in the short term (1 RCT, n = 58, MD 0.10, 95% CI −0.76 to 0.96, low-quality evidence) Low dose compared to standard dose: We found no evidence of effect on mental state between low doses and standard doses of clozapine in terms of both clinician-assessed clinical improvement (2 RCTs, n = 141, RR 0.76, 95%CI 0.36 to 1.61, medium-quality evidence) and clinically important response as more than 30% change in BPRS score (1 RCT, n = 176, RR 0.93, 95% CI 0.78 to 1.10, medium-quality evidence). One study found no difference between groups in BMI in the short term (1 RCT, n = 57, MD 0.20, 95% CI −0.84 to 1.24, low-quality evidence). We found some evidence of effect for other adverse effect outcomes; however, the data were again limited. Very low dose compared to low dose: There was limited evidence that serum triglycerides were lower at low-dose clozapine compared to very low dose in the short term (1 RCT, n = 59, MD 1.00, 95% CI 0.51 to 1.49). Low dose compared to standard dose: Weight gain was lower at very low dose compared to standard dose (1 RCT, n = 27, MD −2.70, 95% CI −5.38 to −0.02). Glucose level one hour after meal was also lower at very lose dose (1 RCT, n = 58, MD −1.60, 95% CI −2.90 to −0.30). Total cholesterol levels were higher at very low compared to standard dose (1 RCT, n = 58, n = 58, MD 1.00, 95% CI 0.20 to 1.80). Low dose compared to standard dose: There was evidence of fewer adverse effects, measured as lower TESS scores, in the low-dose group in the short term (2 RCTs, n = 266, MD −3.99, 95% CI −5.75 to −2.24); and in one study there was evidence that the incidence of lethargy (RR 0.77, 95% CI 0.60 to 0.97), hypersalivation (RR 0.70, 95% CI 0.57 to 0.84), dizziness (RR 0.56, 95% CI 0.39 to 0.81) and tachycardia (RR 0.57, 95% CI 0.45 to 0.71) was less at low dose compared to standard dose. Authors’ conclusions: We found no evidence of effect on mental state between standard, low and very low dose regimes, but we did not identify any trials on high or very high doses of clozapine. BMI measurements were similar between groups in the short term, although weight gain was less at very low dose compared to standard dose in one study. There was limited evidence that the incidence of some adverse effects was greater at standard dose compared to lower dose regimes. We found very little useful data and the evidence available is generally of low or very low quality. More studies are needed to validate our findings and report on outcomes such as relapse, remission, social functioning, service utilisation, cost-effectiveness, satisfaction with care, and quality of life. There is a particular lack of medium- or long-term outcome data, and on dose regimes above the standard rate

Forensic mental health in Europe: shared legal heritage and contemporary landscape

This paper provides an overview of some of the key features of forensic mental health systems around Europe. Forensic mental health systems share in common the aim to assist in the rehabilitation of people diagnosed with a mental disorder and reduce reoffending or risk of harm. How these aims are pursued varies across the continent. We suggest that best practices can be learnt from observing different countries’ approaches. This paper has six foci: legal traditions in Europe, the concept of criminal responsibility, patient pathways through forensic systems, epidemiological studies of forensic patients, training programmes in forensic mental health, and recent developments in the field across Europe. Readers should reflect on these topics in the context of their own country and how these diverge/converge from the countries described in this paper