Understanding the mental health needs of Scotland's prison population: a health needs assessment.

Introduction: This study reports on an assessment of mental health needs among Scotland's prison population which aimed to describe the scale and nature of need as well as identify opportunities to improve upon the services available. The project was commissioned by the Scottish Government to ensure that future changes to the services available to support the mental health and wellbeing of people in prison would be evidence-based and person-centered. Methods: A standardized approach to health needs assessments was employed. The study was comprised of four phases. In phase I a rapid literature review was undertaken to gather evidence on the prevalence of mental health needs experienced by people in prison in the UK. In Phase II a multi-method and multi-informant national mapping exercise involving providers to all Scottish prisons was undertaken to describe the mental health services available, and any gaps in these services, for people in and leaving prison. In Phase III prevalence estimates of several mental health needs were derived for Scotland's current prison population, modeled from a national survey dataset of Scotland's community population using logistic regression. Finally in Phase IV, professional stakeholders and individuals with lived experience were interviewed to understand their experiences and insights on challenges to supporting the mental health and wellbeing of people in prison, and ideas on how these challenges could be overcome. Results: Evidence across the four phases of this needs assessment converged indicating that existing provision to support the mental health of people in prison in Scotland was considered inadequate to meet these needs. Barriers to effective partnership working for justice, health, social work and third sector providers appear to have led to inadequate and fragmented care, leaving prisoners without the support they need during and immediately following imprisonment. Conclusions: Joint and coordinated action from justice, health and social care, and third sector providers is needed to overcome enduring and structural challenges to supporting the mental health of people in prison. Eighteen evidence-based recommendations were proposed to the Scottish Government relating to the high-level and operational-level changes required to adequately meet the prison population's mental health needs.

Randomised controlled trial of the short-term effects of osmotic-release oral system methylphenidate on symptoms and behavioural outcomes in young male prisoners with attention deficit hyperactivity disorder: CIAO-II study.

BACKGROUND: Research has shown that 20-30% of prisoners meet the diagnostic criteria for attention-deficit hyperactivity disorder (ADHD). Methylphenidate reduces ADHD symptoms, but effects in prisoners are uncertain because of comorbid mental health and substance use disorders. AIMS: To estimate the efficacy of an osmotic-release oral system methylphenidate (OROS-methylphenidate) in reducing ADHD symptoms in young adult prisoners with ADHD. METHOD: We conducted an 8-week parallel-arm, double-blind, randomised placebo-controlled trial of OROS-methylphenidate versus placebo in male prisoners (aged 16-25 years) meeting the DSM-5 criteria for ADHD. Primary outcome was ADHD symptoms at 8 weeks, using the investigator-rated Connors Adult ADHD Rating Scale (CAARS-O). Thirteen secondary outcomes were measured, including emotional dysregulation, mind wandering, violent attitudes, mental health symptoms, and prison officer and educational staff ratings of behaviour and aggression. RESULTS: In the OROS-methylphenidate arm, mean CAARS-O score at 8 weeks was estimated to be reduced by 0.57 points relative to the placebo arm (95% CI -2.41 to 3.56), and non-significant. The responder rate, defined as a 20% reduction in CAARS-O score, was 48.3% for the OROS-methylphenidate arm and 47.9% for the placebo arm. No statistically significant trial arm differences were detected for any of the secondary outcomes. Mean final titrated dose was 53.8 mg in the OROS-methylphenidate arm. CONCLUSIONS: ADHD symptoms did not respond to OROS-methylphenidate in young adult prisoners. The findings do not support routine treatment with OROS-methylphenidate in this population. Further research is needed to evaluate effects of higher average dosing and adherence to treatment, multi-modal treatments and preventative interventions in the community.

On the Road to Recovery psychological therapy versus treatment as usual for forensic mental health patients: study protocol for a randomized controlled feasibility trial.

BACKGROUND: On the Road to Recovery (OTRTR) is a brief low intensity group psychological therapy that aims to improve patients' insight into their mental disorder and develop adaptive coping skills to help manage distress. OTRTR is currently delivered in forensic mental health services in Scotland. However, to date, this therapy has not been evaluated as to its effectiveness or safety for forensic patients. METHODS: This is a parallel-group feasibility randomized controlled trial with single-blind assessments comparing OTRTR therapy to treatment as usual (TAU) for forensic mental health patients. Fifty participants will be recruited from high, medium, and low secure forensic mental health services in Scotland. Participants will receive OTRTR for approximately 12 weeks or continue treatment as usual for 12 weeks. The trial's primary aims relate to testing the acceptability and feasibility of key trial procedures that would be necessary for a definitive RCT of OTRTR. The secondary aims include estimating therapeutic effect sizes on clinical outcomes including insight and coping skills. The study design also features an adverse event monitoring plan to estimate the safety of OTRTR for participants, as well as use of intensive longitudinal methods to identify "key ingredients" to the OTRTR therapy protocol. DISCUSSION: This study will inform the design and sample size for a future full-scale randomized controlled trial (RCT), which will be conducted to determine the effectiveness of the On the Road to Recovery intervention in improving forensic mental health patients' clinical insight and coping skills. TRIAL REGISTRATION: ISRCTN Registry, ISRCTN75126867 registered 27 July 2017.

Improving our understanding of the in vivo modelling of psychotic disorders: A protocol for a systematic review and meta-analysis.

Psychosis represents a set of symptoms against which current available treatments are not universally effective and are often accompanied by adverse side effects. Clinical management could potentially be improved with a greater understanding of the underlying biology and subsequently with the introduction of novel treatments. Since many clinical drug candidates are identified through in vivo modelling, a deeper understanding of the pre-clinical field, might help us understand why translation of results from animal models to inform mental health clinical practice has so far been weak. We set out to give a shallow, but broad unbiased overview of experiments looking at the in vivo modelling of psychotic disorders using a systematic review and meta-analysis. This protocol describes the exact methodology we propose to follow in order to quantitatively review both studies characterizing a model and those experiments that investigate the effects of novel therapeutic options. We are interested in assessing the prevalence of the reporting of measures to reduce risk of bias, and the internal and external validity of the animal models and outcome measures used to validate these models. This generation of strong empirical evidence has the potential to identify areas for improvement, make suggestions for future research avenues, and ultimately inform what we think we know to improve the current attrition rate between bench and bedside in psychosis research. A review like this will also support the reduction of animal numbers used in research and the refinement of experiments to maximize their value in informing the field.

Evaluation of a screening instrument for autism spectrum disorders in prisoners.

UNLABELLED: There have been concerns that individuals with autism spectrum disorders (ASDs) are over-represented but not recognised in prison populations. A screening tool for ASDs in prisons has therefore been developed. AIMS: We aimed to evaluate this tool in Scottish prisoners by comparing scores with standard measures of autistic traits (Autism Quotient (AQ)), neurodevelopmental history (Asperger Syndrome (and High-Functioning Autism) Diagnostic Interview (ASDI)), and social cognition (Ekman 60 Faces test). METHODS: Prison officers across all 12 publicly-run closed prisons in Scotland assessed convicted prisoners using the screening tool. This sample included male and female prisoners and both adult and young offenders. Prisoners with high scores, along with an equal number of age and sex-matched controls, were invited to take part in interviews. Prisoners' relatives were contacted to complete a neurodevelopmental assessment. RESULTS: 2458 prisoners were screened using the tool, and 4% scored above the cut-off. 126 prisoners were further assessed using standardised measures. 7 of those 126 assessed scored 32 or above (cut-off) on the AQ. 44 interviews were completed with prisoners' relatives, no prisoner reached the cut-off score on the ASDI. Scores on the screening tool correlated significantly with AQ and ASDI scores, and not with the Ekman 60 Faces Test or IQ. Sensitivity was 28.6% and specificity 75.6%; AUC was 59.6%. CONCLUSIONS: Although this screening tool measures autistic traits in this population, sensitivity for scores of 32 or above on the AQ is poor. We consider that this limits its usefulness and do not recommend that the tool is routinely used to screen for ASDs in prisons.

Facial emotion recognition in Scottish prisoners.

BACKGROUND: Studies of antisocial populations have found that they show deficits in recognition of facial affect. Such deficits are also found in other populations with clinical conditions such as autism spectrum disorders, schizophrenia and obsessive compulsive disorder. AIMS: We aimed to investigate the hypothesis that facial affect recognition in the Scottish prison population would differ from matched controls. In addition, we aimed to investigate any relationship between facial affect recognition deficits and offence history. METHODS: A sample of serving convicted prisoners, drawn from a larger study, was assessed for ability to recognise facial affect. Other variables were also measured and a self-report offending history obtained. RESULTS: 127 prisoners were assessed in 11 prisons. Male prisoners were significantly worse than age, sex and IQ-matched controls at recognising negative facial emotions, specifically anger, fear, sadness and disgust. Within the sample of prisoners, deficits in fear recognition were associated with a history of previous prison sentences but not previous convictions. With respect to offending history, sex offenders were relatively better at recognising sadness and worse at recognising surprise than the other offenders. These relationships remain after controlling for IQ. CONCLUSIONS: Scottish convicted prisoners show deficits in recognising negative facial emotions in a pattern consistent with other antisocial populations. We also demonstrated a relationship between particular patterns of deficit and types of offending history not previously described.

Factors associated with seclusion in a statewide forensic psychiatric service in Australia over a 2-year period.

Despite seclusion being described as one of the most ethically- and legally-controversial management options available, it remains a widely-used clinical strategy for managing disruptive, aggressive, and violent behaviour. This study sought to determine how frequently seclusion was used, the common characteristics of those secluded and not secluded, and the degree to which the Level of Service Inventory - Revised: Screening Version (LSI-R: SV) could predict seclusion. The study was retrospective, covering the first 2 years of operation of a statewide forensic psychiatry hospital in Victoria, Australia. Data were collected from individual case files, electronic databases, and paper copies of records pertaining to violent incidents and episodes of seclusion. Eighty five (44%) of the 193 patients admitted during this period were secluded. Those secluded were significantly younger and had a more established psychiatric history. LSI-R: SV scores were significantly and positively associated with being secluded. A statistical model containing three LSI-R: SV items, along with age on admission and psychiatric history, achieved an area under the curve of 0.74. Seclusion is used on a regular basis in response to a range of different forms of aggressive behaviour of different severity. The LSI-R: SV demonstrated moderate-to-good accuracy in predicting seclusion and warrants further research using detailed prospective methodologies.

Presentations of psychosis with violence: variations in different jurisdictions. A comparison of patients with psychosis in the high security hospitals of Scotland and England.

BACKGROUND: International literature is consistent on there being a significant relationship between psychosis and violence, less so on its extent and nature, but two main presentational types are increasingly recognized. In one, people are unremarkable before onset of illness and psychotic symptoms commonly drive violence; in the other, psychosis is preceded by childhood conduct problems, associated with personality disorder, and psychotic symptoms seem less relevant. AIMS: To explore the extent to which variations in aspects of social and service context in different jurisdictions affect presentational type among people admitted to high security hospitals. HYPOTHESES: There will be differences between jurisdictions in proportions of patients with pure psychosis or with psychosis and antecedent personality disorder, but symptom drive to violence will be more common in the pure psychosis group regardless of social, legal and service context. METHOD: Independently conducted record studies were used to compare high security hospital patients with psychosis in Scotland and England, all resident between 25 August 1992 and 13 August 1993. RESULTS: The cohorts were similar in offence histories, predominance of schizophrenia, age at first hospitalization for psychosis and first high security hospitalization. More Scottish patients had co-morbid substance misuse diagnoses and/or personality disorder than patients in England. Psychotic symptom drive to the index offence was, however, four times more likely in the pure psychosis groups, regardless of sex, ethnic group or country. Scottish patients spent less time in high security after the index act. CONCLUSIONS: Our hypotheses were sustained. Knowledge about lifestyle before onset of psychosis is important for interpreting literature on how psychotic symptoms relate to violence. This may also influence longer term outcome, although the shorter length of secure hospital stay in Scotland was perhaps affected more by greater availability of open 'step-down' beds.

A survey of female patients in high security psychiatric care in Scotland.

BACKGROUND: The State Hospital, Carstairs, is the sole high security psychiatric facility for Scotland and Northern Ireland. METHOD: This study compares the female (n = 28) and male (n = 213) patients resident there between 1992 and 1993 using data derived from case-note reviews and interviews with patients and staff. RESULTS: Nearly three-quarters of both the male and female populations had a primary diagnosis of schizophrenia, and secondary diagnoses of substance abuse and antisocial personality disorder were common. Female patients were more frequently admitted from other psychiatric hospitals, had less serious index offences and more minor previous convictions, and were less likely to be subject to a restriction order. They had more often experienced depressive symptoms and had significantly greater histories of self-harm, physical and sexual abuse. At interview, nearly three-quarters had active delusions and over half had recently behaved in an aggressive manner. Almost 90% were said not to require the security of the State Hospital. CONCLUSIONS: It was concluded that mental illness and adverse social circumstances had combined to create a very disadvantaged group of women in high security psychiatric care in Scotland. As a group these women were inappropriately placed and their requirement was for intensive, rather than high security psychiatric care.

Diet and ageing: the possible relation to reactive oxygen species.

The hypothesis that the generation of reactive oxygen species (ROS) is the principal mechanism responsible for ageing, is reviewed in relation to the influence of diet and dietary factors on the generation of ROS and the effects on life span. Particular focus has been placed on the generation of ROS in the mitochondria, the effects this has on oxidative damage to cellular macromolecules, and the evidence that dietary factors can reduce this damage. Support for the hypothesis that the generation of ROS is a major causative factor in ageing depends on the demonstration that dietary factors, which are antioxidants, or which will reduce the rate of generation of ROS, will increase life span. The experimental evidence so far is not strong, apart from the consistent observation, across many species, that caloric restriction increases longevity. Proof that antioxidants are beneficial is mainly limited to the demonstration that they do increase average life span, principally through a reduction in the incidence of life-threatening diseases in animals, but there is little current evidence to support an increase in maximum life span. Since the experimental approach to date has been phenomenological, rather than mechanistically based, there is a need for further studies to be undertaken looking at specific mechanisms which are known to be influenced by antioxidants.

Dietary contribution to genotoxic risk and its control.

Both exogenous and endogenous mutagens have the potential to contribute to events leading to carcinogenesis. While many dietary exogenous mutagens have been characterized, aflatoxins are the only exogenous mutagens in food which have been shown to directly increase the risk of liver cancer in humans. Little attention has been given so far to endogenous DNA damage, its potential to contribute to carcinogenesis, and the influence of genetic and environmental factors such as the diet on the process. This paper reviews the use of biomarkers which may assist in measuring these effects, their potential use in improving risk analysis for dietary mutagens, their application in molecular epidemiology, and their potential for studying dietary protective factors.

Tattoos.

Tattoo removal is a difficult, risky task that should not be undertaken lightly. Postprocedural scars are inevitable and unavoidable. Salabrasion is often the best removal procedure, if it will work. Also included for discussion are various excision techniques.

Estimation of the dietary intake of chemicals in food.

Methods for estimating the exposure of individuals to chemical substances present in the diet require information to be obtained about the patterns of food consumption in a community as well as the concentration of these chemicals in the diet. Methods of estimating food intakes using food diaries/weighed intake studies, dietary recall studies, food frequency and food disappearance methods are described. Their use, together with calculations derived from the data they provide are described to estimate normal and atypical food consumption patterns. The methods which have been used to estimate the exposure to existing chemicals in food are briefly reviewed and include total diet studies, selective studies on individual foods and duplicate portion studies. These methods are inappropriate for estimating the prospective intake of a chemical in food and the ways in which this issue may be approached, both nationally and internationally, are described with particular reference to the intakes of pesticide residues and food additives.

Zeranol--a 'nature-identical' oestrogen?

The use of implants of zeranol (alpha-zearalanol), a widely-used anabolic growth promoter, in food animals results in very low residues of this compound in the edible tissues. In comparison, residues of myco-oestrogens--specifically the beta-resorcylic acid lactones (RALs) such as zearalenone and its metabolites--commonly found as contaminants of cereals are much greater. Zeranol, the RALs and their metabolites are all closely related chemically, sterically and biologically. The biological effects of these compounds on reproduction, oestrogenicity, teratogenicity, genotoxicity and carcinogenicity are compared. No toxicological effects have been reported that cannot be attributed to the oestrogenic character of these molecules. In comparison with oestradiol, zeranol and the related myco-oestrogens are 100-1000 times less active hormonally. It is concluded that a likely no-observed-effect level (NOEL) for these compounds will be of the order of 0.05-0.1 mg/kg body weight/day. This would result in a safety margin greater than 500-fold between the expected dietary exposure to these compounds (considered together) and the likely NOEL. On the basis of exposure to zeranol alone, this margin of safety would increase to more than 35,000.

Dietary exposure of man to chlorinated benzenes in the United Kingdom.

Chlorinated benzenes are produced in large quantities on a world-wide basis. They are important industrial chemicals, chemical intermediates and components of the waste products of chemical synthesis. Their widespread occurrence and persistence, particularly in the case of the more highly chlorinated benzenes, has resulted in residues in food and human tissues. Information currently available about the levels of residues of these compounds in food has been summarised with particular reference to U.K. data. Estimation of average dietary intake is only possible for the most highly chlorinated compound, hexachlorobenzene, and is calculated to be 0.2 micrograms per person per day. Though insufficient data exist to assess dietary intake of other chlorinated benzenes in the U.K. it is considered unlikely that they would occur at levels greater than hexachlorobenzene in the diet.

A note on inhibition test and electrophoretic detection limits of antibiotics used in British animal husbandry.

A four plate microbiological inhibition test (the FPT) and a bioelectrophoretic method were evaluated for their ability to detect a range of antibiotic agents, which may be present as residues in animal tissues following their therapeutic use in animal husbandry. Both methods exhibited a wide range of sensitivities and several of the tested antibiotics could not be detected by either method. The pattern of responses across the bacterial plates in the FPT could not be used to identify agents and the bioelectrophoretic inhibition zone diameters were generally too large to allow the use of Rs values for identification. The Bacillus subtilis pH 7.2 plate with trimethoprim added was as effective as the four bacterial plates used in the FPT in antibiotic detection.

Reorganization of the British total diet study for monitoring food constituents from 1981.

A total diet study was developed in the UK in the 1960s to enable the estimation of average intakes of different food constituents of public interest. Since that time the organization of the total diet study has twice been modified, firstly in 1975 and more extensively in 1981. The study now includes 115 foods in 20 groups compared to 68 foods in nine groups in the previous design, and reflects more recent food consumption patterns. The food is purchased in preselected parts of the country by a market research company and the preparation of the diets has been centralized in one laboratory instead of being undertaken by domestic science colleges located in many areas. The reorganization is described and the new total diet study is validated by comparison with a study of the previous design.