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To date, psychological theories of aggression have shown limited applicability to the first-hand experience of real-world violence. Examining the experiences of those directly involved in violent offending, may enable professionals to develop a strengthened and more refined understanding. The current study aimed to develop a theoretical model of offender experiences of decision-making, during the commission of a violent offence. The Critical Decision Method (CDM) for cognitive task analysis was conducted within a British prison, with nine participants who had been convicted of a serious violent offence. Interview transcripts were analysed using constructivist Grounded Theory (CGT). Seven themes were interpreted from participant narratives: (i) predisposing influences, (ii) environment, (iii) emotion, (iv) triggering events, (v) decision to act, (vi) identity and (vii) severity of harm caused to the victim. Participants' narratives were found to focus upon a process of decision-making which followed a sequence of events, from the impact of early experiences, through to the in-the-moment decisions, that led to acting in a violent manner. This study provides novel insights into the experience of violent decision-making. Participants emphasised the role of emotion and identity. A range of clinical implications are discussed which highlight the important role of emotion regulation and identity transformation in the rehabilitation of violent offenders. [ABSTRACT FROM AUTHOR]

Accessible Summary: What is known on the subject?: Emergency departments (ED) are key settings to support and manage suicidal crisis; thus, ED staff are often the first point of contact for people in suicidal crisis. Despite this, some ED staff receive little training and/or education on how to best support such patients. What the paper adds to existing knowledge: Previous research focuses on one staffing role (e.g. triage nurses) whereas this paper includes staff working across the ED pathway. Administrative staff have often been excluded from research, despite representing a key part of the clinical pathway and being a person's initial contact with the ED.Overall findings demonstrate that staff experience a lack of confidence, training and burnout due to regularly supporting people in suicidal crisis. Staff also perceive there to be a negative ED culture, which often leads to poor attitudes towards suicidal crisis. The main challenges reported are an increase in working pressures, unavailability of resources and staff retention.Findings build upon previous research to highlight key challenges different staff face along the clinical pathway and the implications this can have on a patient's journey and follow‐up care provided. What are the implications for practice?: Findings are of particular importance and relevance to ED managers, and more broadly NHS England. Negative ED culture, poor staff attitudes and confidence can have a detrimental impact on both staff health and wellbeing, as well as a patient's journey throughout the ED, resulting in repeat presentations and absconding as appropriate support is not received.Policymakers need to consider staff burnout and lack of resources in mental health care strategies, and training programmes should be developed to improve culture and confidence among ED staff and managers to improve care for people attending EDs in suicidal crisis. Introduction: Emergency departments (EDs) are often the first point of contact for people in suicidal crisis. Yet, previous work has tended to focus on only one type of staffing role, failing to account for different staff perspectives along the clinical pathway. Aims: To explore and synthesise the perspectives of ED administrative (i.e. receptionists), medical (triage nurses) and mental health staff (liaison psychiatrists) working with people presenting in suicidal crisis. Method: Qualitative study guided by thematic analysis of semi‐structured interviews with 23 ED staff across six EDs in Cheshire and Merseyside, England. Results: Findings demonstrate that staff experience a lack of confidence, training and burnout due to regularly supporting people in suicidal crisis. The main challenges reported are an increase in working pressures, unavailability of resources and staff retention. Discussion: Staff felt unequipped to deal with suicide‐related presentations. Organisational support is perceived to be lacking, with increased staffing pressures and poor service availability. This lack of support was linked to job dissatisfaction. Implications for Practice: Findings are of particular relevance to individual EDs and NHS England. Addressing the challenges staff are reporting can have positive implications for staff wellbeing, as well as a patient's experience and journey throughout the ED. [ABSTRACT FROM AUTHOR]

Background: NHS England's Transforming Care agenda aims to reduce the number of adults with intellectual disabilities and autistic adults in mental health hospitals. The aim was to understand the demographic and clinical characteristics of those most at risk of admission. Method: A cohort, retrospective study of adults using community intellectual disability services in the North West of England from 2018 to 2022 was undertaken. Results: We compared 211 adults at imminent risk of admission to a mental health hospital and 249 at significant (but not imminent) risk on a validated risk stratification tool. Individuals at significant risk were more likely to have moderate intellectual disability. Individuals at imminent risk were more likely to have diagnoses of mild intellectual disability, autism, personality disorder, or psychosis. Conclusion: By furthering our understanding of the clinical characteristics of those most at risk of admission, the findings inform more appropriate targeting of resources. [ABSTRACT FROM AUTHOR]

Accessible Summary: What the paper adds to existing knowledge?: Personality disorder is a serious mental health condition affecting up to 52% of psychiatric outpatients and 70% of inpatients and forensic patients. People with a diagnosis of personality disorder have higher morbidity and mortality than those without.Service users and carers reported a lack of training for staff in the management of individuals with a diagnosis of personality disorder, particularly with regard to self‐harm and suicidal behaviours.Staff burnout creates barriers to compassionate person‐centred care for individuals with a diagnosis of personality disorder as staff struggled to accommodate the nature of the presentation when under significant emotional, psychological and professional strain caused by understaffing and lack of support. What are the implications for practice?: This paper adds new knowledge by informing services of ways to improve care provision from the perspectives of both carers and service users.A more holistic and less medicalised approach to the treatment of problems associated with a diagnosis of a personality disorder should be adopted, and personality disorder training introduced for all healthcare practitioners, to improve patient outcomes. Introduction: There is limited understanding of the experience of people with complex mental health (CMH) needs, including those with a diagnosis of personality disorder (PD) and carers of those individuals. Little is known about carers of those in inpatient forensic settings, yet it has been identified that they may have additional needs when compared to general carers. Research highlights that community carer support services were perceived as inadequate and out‐of‐area placements were described as putting an added strain on ability to support loved ones. Understanding PD within a population of people with CMH needs and how a diagnosis described as PD impacts on care and treatment experience is vital to providing high‐quality care. Aim: To evaluate the care experience of service users and carers with lived experience of a diagnosis of PD and out‐of‐area placements. Method: Semi‐structured interviews were conducted with six service users and four carers to explore the experiences and perspectives of people with a diagnosis of PD. Interviews were audio recorded and thematically analysed. Results: Four interrelated themes were developed; Influence of a diagnosis of PD on Staff, Early and Appropriate Intervention, Recognition of the Individual and Training and Knowledge of people with a diagnosis of PD. Discussion: Anti‐stigma interventions for staff, research on care provision and structural changes to services including more evidence‐based therapy for individuals with a diagnosis of PD may help reduce disparate treatment and improve prognosis for recovery. Implications for Practice: This paper informs services of ways to improve care provision from the perspective of carers and service users. A more holistic and less medicalised approach to the treatment of problems associated with diagnoses of PD should be adopted, and PD training for all healthcare practitioners to improve patient outcomes. [ABSTRACT FROM AUTHOR]

The Dynamic Appraisal of Situational Aggression (DASA) provides a quick and systematic assessment of short-term violence risk. Risk assessment should be closely aligned to management and result in interventions aimed to reduce risk. The aim of this study was to investigate what interventions followed a moderate/high DASA score and whether they reduced risk. The impact of staff training was also assessed. The study was a retrospective analysis of health records within a medium secure hospital over 6 months. Data was gathered on tool adherence and interventions that were used to reduce risk following a moderate/high score. The change in DASA score following the intervention was recorded. There were 70 patients covering 8224 bed days. There were 24 occasions where a moderate score led to an intervention (n = 24/40%), and 26 occasions for a high score (n = 26/87%). A moderate score was mostly followed by no intervention (n = 35/59%), a high score was mostly followed by seclusion (n = 9/29%). The intervention that led to the largest reduction in DASA score was pro re nata medication following a moderate score and seclusion following a high score. The training of staff led to a reduction in tool adherence and increased intervention use. These results support the need for combining the DASA assessment with operationalised systems to link assessment with risk prevention to help reduce aggression and restrictive practices. [ABSTRACT FROM AUTHOR]

Purpose: The current national patient safety strategy for the National Health Service (NHS) in England states that actions need to be taken to support the development of a patient safety culture. This includes that local systems should seek to understand staff perceptions of the fairness and effectiveness of serious incident management. This study aims to explore the perspectives of patient safety professionals about what works well and what could be done better to support a patient safety culture at the level of Trust strategy and serious incident governance. Design/methodology/approach: A total of 15 professionals with a role in serious incident management, from five mental health trusts in England, were interviewed using a semi-structured interview guide. Thematic analysis and qualitative description were used to analyse the data. Findings: Participants felt that actions to support a patient safety culture were challenging and required long-term and clinical commitment. Broadening the scope of serious incident investigations was felt to be one way to better understand patient safety culture issues. Organisational influences during the serious incident management process were highlighted, informing approaches to maximise the fairness and objectivity of investigation findings. Originality/value: The findings of this study offer original insights that the NHS safety system can use to facilitate progression of the patient safety culture agenda. In particular, local mental health trusts could consider the findings in the context of their current strategic objectives related to patient safety culture and operational delivery of serious incident management frameworks. [ABSTRACT FROM AUTHOR]

Purpose: The need to develop effective approaches for responding to healthcare incidents for the purpose of learning and improving patient safety has been recognised in current national policy. However, research into this topic is limited. This study aims to explore the perspectives of professionals in mental health trusts in England about what works well and what could be done better when implementing serious incident management systems. Design/methodology/approach: This was a qualitative study using semi-structured interviews. In total, 15 participants were recruited, comprising patient safety managers, serious incident investigators and executive directors, from five mental health trusts in England. The interview data were analysed using a qualitative-descriptive approach to develop meaningful themes. Quotes were selected and presented based on their representation of the data. Findings: Participants were dissatisfied with current systems to manage serious incidents, including the root cause analysis approach, which they felt were not adequate for assisting learning and improvement. They described concerns about the capability of serious incident investigators, which was felt to impact on the quality of investigations. Processes to support people adversely affected by serious incidents were felt to be an important part of incident management systems to maximise the learning impact of investigations. Originality/value: Findings of this study provide translatable implications for mental health trusts and policymakers, informed by insights into how current approaches for learning from healthcare incidents can be transformed. Further research will build a more comprehensive understanding of mechanisms for responding to healthcare incidents. [ABSTRACT FROM AUTHOR]

Emergency department (ED) staff are often the first point of contact for individuals in suicidal crisis. Despite this, there is no published research systematically examining the factors influencing decision-making for this patient group. MedLine, CINAHL, PsycINFO, Web of Science and Cochrane Library databases were searched for three key concepts: (1) suicide, (2) accident and emergency department and (3) decision-making. Three reviewers screened titles, abstracts and full papers independently against the eligibility criteria. Data synthesis was achieved by extracting and analyzing study characteristics and findings. The Mixed Methods Appraisal Tool (MMAT) was used to assess the quality of included studies. Seventeen studies met the eligibility criteria and were included in this systematic review. Studies were published from 2004 to 2020 and were of good methodological quality. A number of patient (method of self-harm, age, gender), contextual (availability of services and staff) and staff-related factors (attitudes, training, knowledge) were reported to influence decision-making for patients in suicidal crisis presenting to EDs. Decision-making in the ED is complex and is influenced by patient, contextual and staff-related factors. These decisions can have an impact on the future care and clinical pathways of patients in suicidal crisis. Additional training is needed for ED staff specifically related to suicide prevention. [ABSTRACT FROM AUTHOR]

SUMMARY: Risk assessment in clinical practice is often characterised as a process of analysing information so as to make a judgement about the likelihood of harmful behaviour occurring in the future. However, this characterisation is brought into question when the evidence does not support the current use of risk assessment approaches to predict, or provide probability estimates of, future behaviour in a way that is usable in single instances arising in individual cases. This article sets out a broader and more clinically applicable description of risk assessment which takes account of the wider influences on how this clinical activity takes place. In so doing, it provides a framework to guide clinicians, researchers and authors of practice guidance who are interested in improving approaches to risk assessment. [ABSTRACT FROM AUTHOR]

Objective: Crisis lines are the first mental health service contact point for many people, making them a vital community and public health intervention. Given the current and potential utility of crisis lines, better understanding the characteristics, socioeconomic factors and subsequent referral pathways of callers is critical to identifying targeted ways to improve such services. Study Design: The dataset captured calls to the Cheshire & Wirral Partnership NHS Foundation Trust (CWP) crisis line between August 2020 and August 2021. Calls were examined if self-harm, risk to self, or overdose were reported by the caller. Descriptive analyses were conducted to produce a clinical and demographic profile of the callers using the crisis line. Results: Call handlers were significantly more likely to call 999, hand over to a practitioner and less likely to provide advice and guidance if self-harm, risk to self or overdose was reported. Social issues were found to be significantly associated with all 3 outcomes: self-harm, risk to self and overdose. Conclusion: The current study provides the first exploratory analysis of the socioeconomic factors and resultant care pathways for those contacting a UK crisis line service. The findings have important implications for community early intervention efforts to reduce self-harm and suicidal behaviours. [ABSTRACT FROM AUTHOR]

To improve the safety of healthcare systems, it is necessary to understand harm-related events that occur in these systems. In mental health services, particular attention is paid to harm arising from the actions of patients against themselves or others. The primary intention of examining these adverse events is to inform changes to care provision so as to reduce the likelihood of the recurrence of such events. The predominant approach to investigating adverse incidents has relied on the cause-and-effect conceptualisation of past events. Whilst the merits of approaches which are reliant on cause-and-effect narratives have been questioned, alternatives models to explain adverse incidents in health settings have not been theoretically or empirically tested. This novel article (i) examines the notion of causation (and the related notion of omission) in the context of explaining adverse events in mental health settings, and (ii) draws on a long-established discipline devoted to the study of how the past is interpreted (namely historiography) to theoretically investigate the innovative application of two historiographical approaches (i.e. counterfactual analysis and historical materialism) to understanding adverse events in mental health settings. [ABSTRACT FROM AUTHOR]

Secure mental health services aim to assess and treat mentally disordered offenders, where a patients care pathway involves their movement from service to service on an individual journey towards recovery. Research has attempted to understand the relationship between psychosis and violence for mentally disordered offenders. From this empirical evidence base a tripartite typology has emerged. Three subgroups have been categorised as (i) schizophrenia preceded by conduct disorder (SZ+CD), (ii) offenders with schizophrenia who begin offending at illness onset (SZ+AS), and (iii) offenders with schizophrenia (SZ). This study aimed to examine differences in care pathways between subgroups. The sample consisted of 77 male patients admitted to low- and medium-secure care. The subgroup of patients was determined from data collected from health records. The analysis examined the differences in patient care pathways. The results demonstrated differences in subgroup pathways to, within and from secure services. The SZ+CD subgroup had a higher number of placements used, were more likely to transition between the same level of security, and had an increased use of the private sector. The SZ+AS subgroup was significantly more likely to use intensive care and less likely to use high secure services. Examining care pathways of mentally disordered offenders will ensure a more evidence-based approach to the configuration and operationalisation of services, help guide policymakers and hopefully improve patient care. [ABSTRACT FROM AUTHOR]

Emergency departments (EDs) are often the first point of contact for individuals following self-harm. The majority of previous research relies on hospital-based data, yet only a minority of individuals who self-harm in the community present to healthcare services. The study design is cross-sectional survey design. Data from the National Institute for Health Research Applied Research Collaboration North West Coast (NIHR ARC NWC) Household Health Survey, a community-based public health survey in North West England, was collected using stratified random sampling. Three thousand four hundred twelve people were recruited in 2018 from relatively disadvantaged areas. The sample included 1490 men and 1922 women aged 18 to 100 years (M = 49.37, SD = 18.91). Logistic regression analysis was employed to examine demographic, health and socioeconomic predictors of self-harm and ED attendance for self-harm. Age (18–24 years), lower financial status, depression, anxiety and physical and mental health co-morbidity was associated with significantly higher levels of self-harm. People aged 18–24 years, with physical and mental health co-morbidity and lower levels of social support had significantly higher levels of attending EDs for self-harm. Improving people's financial situations, social connectivity, mental and physical health may help to reduce individual risk for self-harm and strain on health services. [ABSTRACT FROM AUTHOR]

Purpose: New patient safety frameworks are being implemented to improve the impact of incident reporting and management across the National Health Service (NHS) in England. This study aims to examine the current practices in this domain of patient safety in a sample of mental health trusts, a setting in which limitations in the current practice of serious incident management have been reported. The authors present key recommendations to maximise the opportunities to improve current incident reporting and management practice. Design/methodology/approach: Ethical approval for the study was granted. A Web-based questionnaire was designed to examine current practices concerning incident reporting and management. It was refined based on consultation. Patient safety incident managers within mental health trusts in England were recruited. Twenty-nine mental health trusts responded, from a total of 51. The questionnaire study data were analysed in Statistical Package for the Social Sciences. Findings: Current approaches used to report and manage incidents have been established and variation in practice demonstrated. A key finding for attention is that the training and education that investigators of serious incidents receive falls short of the recommended minimum national standard of 15 h, with a sample mean of 10.3 h and median of 8.0 h. Originality/value: Recommendations at a local and national level are presented, which, if implemented, can maximise the impact of incident reporting and management practices in mental health trusts. Future qualitative research is indicated, to understand the perceptual experience and meaning behind the findings across a wider group of stakeholders. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of the study was to examine whether there were differences in the provision of non-pharmacological interventions based on the level of intellectual disability and the presence or absence of autism. Mental health conditions are often underdiagnosed in adults with intellectual disability and do not always receive psychological interventions as recommended by the National Institute for Health and Care Excellent guidelines. To realise the national UK programme's aim of stopping the overuse of medications in people with intellectual disability, it is important that these individuals have access to appropriate non-pharmacological interventions. The authors examined the relationship between an individual's level of intellectual disability and the presence or absence of autism with access to relevant non-pharmacological interventions from specialist community intellectual disability services. Design/methodology/approach: A cross-sectional study of adults accessing four specialist intellectual disability services in North West England in 2019. Findings: There was a high prevalence of mental health comorbidity, even higher for autistic adults. However, a relatively small percentage of the study population was receiving psychological interventions. The most frequent non-pharmacological intervention was a positive behaviour support plan, irrespective of comorbid mental illnesses. Research limitations/implications: Not having access to psychological interventions for the treatment of mental illness could result in poor health outcomes and increasing health inequalities. The study highlights the need for developing psychological interventions, particularly for those with moderate to severe intellectual disability and for those with associated autism. Originality/value: This large sample study examined the relationship between intellectual disability level and the presence of autism with accessing psychological interventions. [ABSTRACT FROM AUTHOR]

Three pathways of antisocial behaviour and psychosis have been described. Three subgroups within a typology have been categorised as (i) schizophrenia preceded by conduct disorder (SZ+CD), (ii) offenders with schizophrenia and no childhood history of antisocial behaviour who begin offending at illness onset (SZ+AS), and (iii) offenders with schizophrenia (SZ). There are no studies investigating how the subgroups utilise services. This study aimed to examine the concurrent validity of typology and examine differences in service utilisation. The sample consisted of 77 male patients admitted to low- and medium-secure units in the United Kingdom. The subgroup of patients was determined from data collected from health records. Analysis assessed the difference in aetiological variables amongst the typology and examined the relationship of subgroup service utilisation. This study provided further evidence of distinguishing characteristics emphasising typology heterogeneity and found differences in service utilisation. The SZ+CD subgroup was more likely to have used services preceding a diagnosis of psychosis. Following the onset of psychosis, the SZ+AS and SZ subgroups had a higher proportion that used general adult psychiatry services. Those patients within the SZ+AS and SZ subgroups had a higher use of general adult services after psychosis onset. Understanding about how these subgroups utilise services will enable clinicians to develop effective management plans that address the distinct characteristics of offenders with psychosis. [ABSTRACT FROM AUTHOR]

Purpose: This study aims to evaluate the quality of transition from child and adolescent services to adult intellectual disability services, using the relevant National Institute for Health and Care Excellence (NICE) standard (QS140). In addition, this study also identifies any differences in transition quality between those young people with intellectual disability with and without autism. Design/methodology/approach: Using routinely collected clinical data, this study identifies demographic and clinical characteristics of, and contextual complexities experienced by, young people in transition between 2017 and 2020. Compliance with the quality standard was assessed by applying dedicated search terms to the records. Findings: The study highlighted poor recording of data with only 22% of 306 eligible cases having sufficient data recorded to determine compliance with the NICE quality standard. Available data indicated poor compliance with the standard. Child and adolescent mental health services, generally, did not record mental health co-morbidities. Compliance with three out of the five quality statements was higher for autistic young people, but this only reached statistical significance for one of those statements (i.e. having a named worker, p = 0.02). Research limitations/implications: Missing data included basic clinical characteristics such as the level of intellectual disability and the presence of autism. This required adult services to duplicate assessment procedures that potentially delayed clinical outcomes. This study highlights that poor compliance may reflect inaccurate recording that needs addressing through training and introduction of shared protocols. Originality/value: To the best of the authors' knowledge, this is the first study to examine the transition process between children's and adults' intellectual disability health services using NICE quality standard 140. [ABSTRACT FROM AUTHOR]

Purpose: Despite repeated policy initiatives, progress in improving patient safety in the National Health Service (NHS) in England over the past two decades has been slow. The NHS Patient Safety Strategy (NHS England and NHS Improvement, 2019), which is being implemented currently, aims to address this problem. The purpose of this study is to identify learning from the implementation of past patient safety policies and thereby suggest means of supporting the NHS in delivering the current policy initiative successfully. Design/methodology/approach: The authors identified key health policies in the domain of patient safety, published since 2000, by searching the United Kingdom (UK) government website. Discussion papers from the research literature concerning these policies were collated and reviewed. The authors then used a thematic analysis approach to identify themes discussed within these papers. These themes represent factors that support the effective delivery of patient safety policy initiatives. Findings: Within the discussion papers the authors collated, concerning 11 patient safety policies implemented between 2000 and 2017, five inter-related core themes of capability, culture, systems, candour and leadership were identified. By evaluating these themes and identifying composite sub-themes, a conceptual framework is presented that can be used to support the delivery of patient safety policy initiatives to maximise their impact. Originality/value: The conceptual framework the authors illustrate, arising from this new contribution to the body of knowledge, can be translated into a novel self-assessment for individual NHS trusts to understand organisational development areas in the domain of patient safety improvement. [ABSTRACT FROM AUTHOR]

Background: Mental health services for adults, as they are currently configured, have been designed to provide predominantly community-based interventions. It has long been recognised that some patients have such significant clinical and/or risk needs that those needs cannot be adequately met within standard service delivery models, resulting in a pressing need to consider the best models for this group of people. This paper shares a protocol for a mixed methods study that aims to understand: the profile and history of service users described as having complex needs; the decision-making processes by clinicians that lead to complex needs categorisation; service users and carers experience of service use; and, associated economic impact. This protocol describes a comprehensive evaluation that aims to inform an evidence-based service delivery model for people with complex needs. Methods: We will use a mixed methods design, combining quantitative and qualitative methods using in-depth descriptive and inferential analysis of patient records, written medical notes and in-depth interviews with service users, carers, and clinicians. The study will include five components: (1) a quantitative description and analysis of the demographic clinical characteristics of the patient group; (2) an economic evaluation of alternative patient pathways; (3) semi-structured interviews about service user and carer experiences; (4) using data from components 1–3 to co-produce vignettes jointly with relevant stakeholders involved in the care of service users with complex mental health needs; and, (5) semi-structured interviews about clinical decision-making by clinicians in relation to this patient group, using the vignettes as example case studies. Discussion: The study's key outcomes will be to: examine the resource use and cost-impact associated with alternative care pathways to the NHS and other sectors of the economy (including social care); explore patient health and non-health outcomes associated with alternative care pathways; and, gain an understanding of a complex service user group and how treatment decisions are made to inform consistent and person-centred future service delivery. [ABSTRACT FROM AUTHOR]

SUMMARY: Significant developments in schizophrenia psychopathology are ready to be incorporated into clinical practice. These advances allow a way forward through the well-described challenges experienced with current diagnostic and psychopathological frameworks. This article discusses approaches that will enable clinicians to access a wider and richer spectrum of patient experience; describes process-based models of schizophrenia in the domains of both the brain and the mind; and considers how different levels of analysis might be linked via the predictive processing framework. Multiple levels of analysis provide different targets for varying modalities of treatment – dopamine blockade at the molecular level, psychological therapy at the level of the mind, and social interventions at the personal level. Psychiatry needs to align itself closer to neuroscientific research. It should move from a symptom-based understanding to a model based on process. That is – after having asked about a patient's symptoms and experience clinicians need to introduce steps involving a consideration of what might be the brain and mind processes underlying the experience. [ABSTRACT FROM AUTHOR]

In everyday mental health practice, clinicians are expected to assess and manage the risk of harm that may be caused by their patients to others. An informed approach to the activities of risk assessment and management should be grounded in a thorough understanding of the notion of risk. Whilst there are agreed definitions of risk, they do not do justice to the complexity of in-vivo representations of risk. Based on a review of the literature, an analysis of clinical guidelines, and practicing psychiatrists' reflections on their own clinical experiences and sample vignettes, this article explores the varied subjective representations of risk in mental health practice. Of specific relevance to the possibility of an individual causing harm is the need to recognise that the causal agent of harm is an as-yet-unrealised state of consciousness, and that actions that may reduce risk are multiple and have effects that are difficult to define in advance. From an analysis of the semantic context of the use of the word 'risk' within practice guidance, the authors demonstrate a wide range of meanings (including harm, possibility of harm, characteristics of possible harm, a state with changeable potential for harm, and different states of potential harm) with different degrees of embodiment. With reference to clinical scenarios, the formation of individual subjective representations of risk are shown to vary not only in the way they can be characterised (e.g. likelihood, severity, and imminence), but also in the extent to which they come into subjective focus. Uncovering the different ways risk is represented in practice should allow a more refined approach to guiding and studying the process of risk assessment and management. [ABSTRACT FROM AUTHOR]

Background: Human decision-making involves a complex interplay of intra- and inter-personal factors. The decisions clinicians make in practise are subject to a wide range of influences. Admission to a psychiatric hospital is a major clinical intervention, but the decision-making processes involved in admissions remain unclear. Aims: To delineate the range of factors influencing clinicians' decisions to arrange acute psychiatric admissions. Methods: We undertook six focus groups with teams centrally involved in decisions to admit patients to hospital (crisis resolution home treatment, liaison psychiatry, approved mental health practitioners and consultant psychiatrists). The data were analysed using qualitative thematic analysis. Results: Our analysis of the data show a complex range of factors influencing decision-making that were categorised as those related to: (i) clinical and risk factors; (ii) fear/threat factors; (iii) interpersonal dynamics; (iv) contextual factors. Conclusions: Decisions to arrange acute admission to hospital are not just based on an appraisal of clinical and risk-related information. Emotional, interpersonal and contextual factors are also critical in decision-making. Delineating the breadth of factors that bear on clinical decision-making can inform approaches to (i) clinical decision-making research, (ii) the training and supervision of clinicians, and (iii) service delivery models. [ABSTRACT FROM AUTHOR]

SUMMARY: Substance misuse worsens the prognosis for people suffering psychosis and places them at risk of being denied appropriate mental health service interventions. To increase the chances of its success, the plan of management for patients with coexisting psychosis and substance misuse should be based on a valid formulation of their problems, which in turn is dependent on the clinician having (a) a thorough understanding of the bidirectional and changing ways that substance use and mental illness symptoms can interact, (b) an awareness of their own biased implicit assumptions about causality in explaining these interactions and (c) a framework for assessment and formulation. This article addresses these three areas with reference to the evidence base and to clinical experience in a way that guides mental health clinicians in the assessment of patients with coexisting psychosis and substance misuse. [ABSTRACT FROM AUTHOR]

SUMMARY: Approaches to assessing violence in clinical practice have been influenced by developments in the field of risk assessment. As a result, there has been a focus on identifying and describing factors associated with violence. However, a factor-based approach to assessing violence in individual cases has limited clinical utility. In response, the benefits of a formulation-based approach have been promoted. This approach is enhanced by an understanding of the specific mental mechanisms that increase the likelihood of violence in the individual case. Although there is an empirical evidence base for mental mechanisms associated with violence, this literature has not been distilled and synthesised in a way that informs routine clinical practice. In this article the authors present the key mechanisms that are known to be associated with violence in a way that is relevant to the clinical assessment of violence and, in turn, can inform clinical and risk management. [ABSTRACT FROM AUTHOR]

SUMMARY: Psychiatric assessments of adults involved in care proceedings can play a critical role in assisting the family court to resolve proceedings justly. To properly carry out this role, the psychiatric expert should have an up-to-date understanding of the wider context within which they are working. This article outlines the legal framework of care proceedings in England and Wales and summarises the key aspects of the process. The duties of the expert and how the expert is engaged are explained. Finally, guidance is presented on how the expert should approach questions that are commonly raised in these proceedings. LEARNING OBJECTIVES: After reading this article you will be able to: • appreciate the legal framework relevant to care proceedings in England and Wales • recognise the circumstances in which expert psychiatric evidence relating to adults in care proceedings is commissioned • understand the common questions posed to expert psychiatrists undertaking assessments of adults in care proceedings and develop an assessment framework. [ABSTRACT FROM AUTHOR]

Background: High demand for health services is an issue of current importance in England, in part because of the rapidly increasing use of emergency departments (EDs) and GP practices for mental health conditions and the high cost of these services.Aim: To examine the social determinants of health service use in people with mental health issues.Design and Setting: Twenty-eight neighbourhoods, each with a population of 5000-10 000 people, in the north west coast of England with differing levels of deprivation.Method: A comprehensive public health survey was conducted, comprising questions on housing, physical health, mental health, lifestyle, social issues, environment, work, and finances. Poisson regression models assessed the effect of mental health comorbidity, mental and physical health comorbidity, and individual mental health symptoms on ED and general practice attendances, adjusting for relevant socioeconomic and lifestyle factors.Results: Participants who had both a physical and mental health condition reported attending the ED (rate ratio [RR] = 4.63, 95% confidence interval [CI] = 2.86 to 7.51) and general practice (RR = 3.82, 95% CI = 3.16 to 4.62) more frequently than all other groups. Having a higher number of mental health condition symptoms was associated with higher general practice and ED service use. Depression was the only mental health condition symptom that was significantly associated with ED attendance (RR = 1.41, 95% CI = 1.05 to 1.90), and anxiety was the only symptom significantly associated with GP attendance (RR = 1.19, 95% CI = 1.03 to 1.38).Conclusion: Mental health comorbidities increase the risk of attendances to both EDs and general practice. Further research into the social attributes that contribute to reduced ED and general practice attendance rates is needed. [ABSTRACT FROM AUTHOR]

Psychiatric expert witnesses instructed to undertake assessments of defendants charged with murder should be familiar with the partial defences of diminished responsibility and loss of control. The Coroners and Justice Act 2009 enacted major amendments to the partial defence of diminished responsibility and introduced a new defence of loss of control to replace the provocation partial defence. In this article, the changes to the law are described with particular focus on the implications for the psychiatric assessment. [ABSTRACT FROM AUTHOR]

This paper describes the experiences of a Forensic Autism Spectrum Disorder Assessment and Liaison team. We reflect upon the processes and complexities of assessment, formulation and care pathway planning for this population within forensic contexts. [ABSTRACT FROM AUTHOR]

Introduction: Mental health services for adults have been developed to provide community-based interventions. There is a recognized unmet need in some of the most complex patients that may not be adequately met by existing mental health services provision. Research is warranted to consider the best model of service delivery for this group of service users. The aims of this research were to examine the profile and history of service users defined as having complex needs as well as their service use and associated costs in the Cheshire and Wirral Partnership NHS Foundation Trust (CWP). Methods: A diverse group of stakeholders were invited to provide feedback on the content and design of the proforma for data collection from the medical records of service users. The rationale of the data collection was described to ensure relevant patient-level cost information was collected to identify and quantify the relevant resources consumed, to inform the evaluation of direct medical costs, direct non-medical costs, and indirect costs for each patient. The proforma was designed to also permit comparisons of clinical and service use outcomes for evaluation of patient health and non-health outcomes associated with alternative care pathways. Results: Stakeholder feedback comprised representatives from the CWP, patients, commissioners, the Local Authority, and housing. Relevant data for extraction from patient medical records were identified and a proforma was developed. The following items were identified for inclusion: baseline demographic data, service user data (family background, contact with the criminal justice system, social history), and clinical data (diagnosis, treatment, hospital visits, and other health service use). Conclusions: A proforma was developed with diverse stakeholder involvement to inform data collection on the resource use and cost impact associated with alternative care pathways in the National Health Service and other sectors of the economy. Based on the proforma developed and data extracted, an exploration of patient health and non-health outcomes associated with alternative care pathways will be conducted to inform service evaluation and to promote patient centric care. [ABSTRACT FROM AUTHOR]

Background: Dynamic risk factors need to be assessed repeatedly over time rather than at a single time point to examine the relationship with violence. This predictive validity study sought to examine the degree of dynamic change in risk assessed in a group of mentally disordered offenders and the relationship between change and the occurrence of violence. Methods: Routine structured assessments of Strengths and Vulnerabilities on the Short-Term Assessment of Risk and Treatability (START) instrument (n = 475) were linked prospectively with 275 violent incidents using logistic regression in a sample of 50 patients. Results: Stability within patients estimated using the intra-class correlation coefficient was high (>.80) for both Strengths and Vulnerabilities. In the overall sample, a 10 point increase in START Vulnerabilities score was associated with a three-fold increased risk of violence (OR = 3.1; 95% CI, 1.47-7.46) but there was no association for Strengths score (OR = 0.91, 95% CI, 0.34-2.47). When examined within patients, both Vulnerabilities (OR = 1.77, 95% CI, 0.56-5.54) and Strengths (OR = 2.26, 95% CI, 0.38-13.42) were associated with an increased risk of violence but in both cases precision was low due to reduced sample sizes. Conclusions: Risk factors which are considered to have the capacity to fluctuate dynamically did not do so substantially in this group of mentally disordered offenders. When fluctuations did occur there was some tentative evidence that they are associated with violent outcomes and could guide the use of prevention measures. [ABSTRACT FROM AUTHOR]

Purpose – The profile of personality disorder in forensic clinical practice has been raised by key developments over the last decade, although services remain in the large part piecemeal and disconnected. This paper aims to describe the lessons learnt from the development of one specialist service for personality disordered offenders. Design/methodology/approach – The policy context in which the service was developed, the challenges of working in this area, and data relating to the clinical and risk profile of referred cases are presented. Findings – Data demonstrate extensive comorbidity and heterogeneity amongst those referred to the service. With reference to the experience gained in the first four years of the service, it is suggested that a systematic and formalised model of "understanding" the psychology of the individual should be the core process of future developments for this group of offenders, and subsequently recommendations are made to enhance the practical utility of such formulations rate. Research limitations/implications – Conclusions are mostly based on expert opinion and upon one particular service provision, and therefore care should be exercised in generalising the results of this study to existing services. The need for further research in order to enhance knowledge and understanding of this complex group is highlighted. Practical implications – The heterogeneity and comorbidity within this group of offenders emphasises the need for services to offer a range of assessment methods and interventions to meet individuals' requirements. Originality/value – The experiences and recommendations in this paper are valuable to professionals working with personality disordered offenders and to the development of more extensive services for such individuals. [ABSTRACT FROM AUTHOR]

Prospective longitudinal studies have shown strong predictions from conduct disorders (CDs) in childhood to antisocial personality disorder (ASPD) and violence in adults. However, little is known of the childhood antecedents of serious violence nor whether these may vary depending on the context in which the violence occurs. In this study, 54 men aged 21–40 years serving prison sentences for violent crime were assessed. Standardized interviews of ASPD and violence were conducted independently of interviews covering retrospective recall of childhood psychiatric disorders and adverse experiences. Analyses of the predictors of overall violence suggested a pathway involving childhood CD and adult ASPD associated with interparental discord, and an additional pathway associated with experiencing interparental violence in childhood. Different results were however obtained when account was taken of the context of the violence. The CD–ASPD pathway was associated with social violence, but not with partner violence. Partner violence was predicted by retrospective reports of having been exposed to interparental violence during childhood but not by reports of childhood CD or adult ASPD. Thus developmental pathways to serious violence may be different depending on the social domain in which the violence occurs. Aggr. Behav. 34:329–338, 2008. © 2008 Wiley-Liss, Inc. [ABSTRACT FROM AUTHOR]

A work environment characterized by frequent emotionally-charged interactions increases the risk of staff burnout. It was hypothesized that gender differences in psychopathology in forensic mental health settings may be associated with differences in the risk of burnout. The development of single-sex accommodation in a medium secure facility provided an opportunity to examine the impact of such patient gender differences within a therapeutic setting. In this study, nurses allocated to work on a new women's ward were assessed for burnout before the ward opened and a subgroup was re-assessed 18 months later. A comparison group of nurses working on a men's ward were assessed at the same two time points. Nurses working on the women's ward experienced a significantly greater increase in the emotional exhaustion component of burnout. There was some indication of a similar process for the depersonalization component. The implications of these findings are discussed in the context of the literature relating to the psychopathological and interpersonal differences between male and female patients and relating to the responses of clinicians to these differences. [ABSTRACT FROM AUTHOR]

Background: Antisocial personality disorder (ASPD) identifies adults with persistent offending behaviour and social dysfunction. However, it lacks discrimination within high-risk and criminal populations and gives little indication of an individual's history of violence. Existing measures of violence have significant limitations. The Liverpool Violence Assessment (LiVA) is an investigator-based standardized interview for measuring patterns of violence.Method: A total of 61 male prisoners who had been sentenced for serious violent offences were interviewed using the LiVA and the Structured Clinical Interview for DSM IV antisocial personality disorder and alcohol and drug dependence. Official records of offending were examined.Results: The inter-rater reliability for the LiVA was high. There were significant correlations between histories of violence assessed by the LiVA and official records, but the frequency of self-reported violence was much higher than in the official records. Antisocial personality disorder was associated with increased violence. However, analyses revealed marked variability of the levels of violence among those with antisocial personality disorder and contrasting patterns of association of violence with antisocial personality disorder depending on the context.Conclusion: The LiVA is a reliable and valid measure of the patterns and characteristics of violence. The findings suggest that the causes of violence should be studied in their own right and not only as a feature of ASPD. [ABSTRACT FROM AUTHOR]