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Faculty of Forensic Psychiatry Annual Conference 2nd – 4th February 2011 Radisson Blu Hotel, Berlin, Germany Final Programme and abstracts Front cover images courtesy of http://www.google.co.uk/images?hl=en&expIds=17050,25657,27702,27955&xhr=t&q=images+of+berlin&cp=13&wrapid=tljp1295361113772027&um=1&ie=UTF8&source=univ&ei=BKU1TZPZNYmfOtTLubYC&sa=X&oi=image_result_group&ct=title&resnum=1&sqi=2&ved=0CCsQsAQwAA&biw=1259&bih=818 WEDNESDAY 2nd FEBRUARY 08.25-09.20 (Foyer) Registration, coffee and exhibition viewing 09.25 Saphirs 1 & 2 Introductory remarks and welcome Dr Janet Parrott Clinical Director and Consultant Forensic Psychiatrist Bracton Clinic, Dartford, UK SESSION 1: Keynote speech Chair: Professor Jenny Shaw, University of Manchester, UK 09.30 Keynote Speech: Developments in Offender Health Professor Louis Appleby National Clinical Director for Health and Criminal Justice and Professor of Psychiatry at the University of Manchester, UK SESSION 2 – Commissioning Secure Services and Payment by results Chair: Dr Paul Gilluley, West London Mental Health Trust, UK 10.15 The Medium Secure QIPP Challenge Dr Elizabeth Allen , National Mental Health Development Unit, UK 10.45 PbR in Forensic Psychiatry: The Story So Far Mr Nick Broughton, Medical Director, West London Mental Health Trust, UK 11.15-11.40 (Foyer) Coffee and exhibition viewing Saphirs 1 & 2 SESSION 3: Treatment of Sexual Offending Chair: Professor Don Grubin, Newcastle University, UK 11.40 Sex Offender Treatment in Correctional Settings Dr Ruth Mann , Rehabilitation Services Group National Offender Management Service HM Prison Service, UK 12.20 Treatment of Sex Offenders Professor Richard Krueger, Medical Director, Sexual Behaviour Clinic New York State Psychiatric Institute & Columbia University Department of Psychiatry, USA 13.00-14.00 (Foyer) Lunch and exhibition viewing SESSION 4: UPDATE YOUR CLINICAL PRACTICE Pick and mix parallel sessions- 14.00 Parallel session 1 Parallel session 2 Chair: Professor Philip Sugarman, Chair: Dr Quazi Haque St Andrew‘s Healthcare, UK Priory Group and Institute of Psychiatry, UK Saphir 1 Saphir 2 Self Harm and Suicide Professor Nav Kapur University of Manchester, UK Offending Behaviour Programmes Professor James McGuire Liverpool University, UK 14.30 Depression Update Professor Ian Anderson University of Manchester, UK Issues of good prescribing practice/new drug developments Professor David Taylor Director of Pharmacy and Pathology South London and Maudsley NHS Foundation Trust Pharmacy, UK 15.00 Misuse of “new” substances Professor Mike Farrell Institute of Psychiatry, UK Metabolic Syndrome Professor Christopher Byrne The Institute of Developmental Sciences University of Southampton, UK 15.30 Developments in offender health Dr Andrew Forrester South London & Maudsley, London, UK Developing a Psychological Therapies Programme for MSUs Dr Tim Green South London & Maudsley, London, UK 16.00-16.25 (Foyer) Tea and exhibition viewing 16.30 Saphir 1& 2 SESSION 5: DISCUSSION: Moral Maze - Is Forensic Psychiatry Ethical? Discussants include a panel of clinicians and lawyers Chair: James Anderson Bracton Centre, Oxleas NHS, UK David James, Consultant Forensic Psychiatrist and Director, FTAC, UK Jackie Craissati, Principal Clinical Psychologist and Clinical Director, Bracton Centre, UK Adrian Grounds, Institute of Criminology, University of Cambridge, UK Ashley Irons, Partner, Capsticks Solicitors, UK 17.40 Brief introduction to Bethlem Archive Art Exhibit 17.50 End of session 18.00-19.00 (Foyer) Delegates from outside the UK and Ireland, Trainees and Medical Students are invited to join us for a drinks reception at the Radisson Hotel The Radisson Blu Berlin Aquarium: Have you zipped up and down in an elevator encased inside the largest acrylic glass cylinder aquarium in the world? THURSDAY 3rd FEBRUARY 08.30-09.10 (Foyer) Registration, coffee and exhibition viewing Saphirs 1 & 2 09.15 09.45 SESSION 6: Personality Disorder Masterclass Chair: Professor Jeremy Coid, Barts & The London School of Medicine, UK Biology of Personality Disorder Professor Bill Deakin, University of Manchester, UK Treatment of Borderline Personality Disorder Professor Anthony Bateman, St Anns Hospital London, UK 10.15 The future of DSPD Mr Nick Benefield and Mr Nick Joseph, Department of Health, London, UK 10.45 The Netherlands Experience Professor Hjalmar Van Marle, University Medical Centre Rotterdam , Netherlands 11.20 Discussion 11.30-11.55 (Foyer) Coffee and exhibition viewing Saphir 1 & 2 SESSION 7: Keynote Lecture Chair: Professor Nigel Eastman, SGHMS, London, UK 12.00 Spree and Mass Killers: An Analysis of Extreme Violence Professor Jack Levin, Northeastern University of Boston, USA 13.00-13.55 (Foyer) Lunch and exhibition viewing SESSION 8: PARALLEL WORKSHOPS 14.00-15.30 Delegates are invited to ‘pick and mix’, changing between rooms during the sessions to make up their own programme. Please note that attendance is on a first come first served basis on the day, subject to the room space available 14.00 Saphir 1 Workshop 1 Adolescent and Young Adults Forensic Services Paul Monks, Heidi Hales, Enys Delmage & Ash Roychowdhury 14.00 Saphir 2 Workshop 2 Relational Security Paul Gilluley, Bradley Hillier and James Tighe 14.00 Rubin Workshop 3 Substance misuse interventions in forensic services Niamh Power, Julia O‘Connor and Alex Whale 14.00 Aquamarin Workshop 4 Mentalization and group reflective practice in the management of forensic personality-disordered patients; Jessica Yakeley, Andrew Williams and Gill McGauley, Roberta Babb, John Canning, and Cleo Van Velsen 14.00 Jade 1 & 2 Workshop 5 New versus old- Diminished Responsibility Nigel Eastman, Sathana Gunasekaran and Nuwan Galappathie 14.00 Turmalin 1 & 2 Workshop 6 Trauma and criminal behaviour: assessment and treatment of post-traumatic syndromes in forensic settings Vittoria Ardino, Frances Maclennan, Piyal Sen and Andrew Forrester 15.30 (Foyer) 16.00 Turmalin 1 & 2 Tea and exhibition viewing SESSION 9: PARALLEL WORKSHOPS 16.00-17.30 Delegates are invited to ‘pick and mix’, changing between rooms during the sessions to make up their own programmes Workshop 7 Forensic services and commissioning in the economic downturn Dr Paul Gilluley, Dr Jeremy Kenney-Herbert, Dr Quazi Haque, Dr Mehdi Veisi, Mike Gatsi, Mrs Jill Lockett, Dr Mary Whittle 16.00 Saphir 1 Workshop 8 Sex Offenders Sodi Mann and Don Grubin 16.00 Saphir 2 Workshop 9 Avoiding Grief in Court John Kent, David Reiss, Aideen O‘Halloran & Ashley Irons, partner at Capsticks Solicitors 16.00 Jade 1 & 2 Workshop 10 Service User Involvement in a Medium Secure Dangerous and Severe Personality Disorder Unit Caitriona Higgins Victoria Wasteney, Emma Chandler, Celia Taylor 16.00 Rubin Workshop 11 Film Club - The Lives of Others (Director Florian Henckel von Donnersmarck,2006) Cleo van Velsen 16.00 Aquamarin Workshop 12 Managing Violent Personality Disordered Women in Psychologically Containing Planned Environments – a strategy for the future Mary DiLustro, Jay Sarkar 18.00 18.15 Additional Meeting: AFPSIG Business Meeting Fun Run! Walk, jog or sprint. Delegates are invited to burn of some calories on the streets of Berlin. Meet outside the conference hotel. Route details will arranged by Dr Deirdre MacManus and her athletic colleagues and will be confirmed at the conference. Delegates who wish to participate in the fun run should sign on at the conference registration desk. 19.45 Drinks Reception and Conference Dinner–Radisson Blu Hotel Exclusive booking! Enjoy a three course meal & panoramic city views The conference dinner is not included in the whole conference fee. If you wish to attend contact the Conference Team at the Registration Desk. FRIDAY 4TH FEBRUARY 08.25-08.40 (Foyer) Registration, coffee and exhibition viewing 08.45 Saphirs 1 & 2 FORENSIC FACULTY REPORT AND BUSINESS MEETING 9.30 SESSION 10: NEW RESEARCH PRIZE PRESENTATIONS Judges: Professor Jeremy Coid, Prof Norbert Nedopil, Professor Phillip Sugarman 09.30 The prevalence and predictors of violent victimisation amongst male inpatients in six English Regional Secure Units Presenter: Dr Sophie Anhoury, UK 09.45 A simple screening tool for violence risk in schizophrenia Presenter: Dr Seena Fazel, UK 10.00 Audit of the transfer of prisoners from HMP Isle of Wight to mental health hospitals Presenter: Dr Tamsin Peachy, UK 10.15 Volumetric structural abnormalities of the Amygdala and Hippocampus in men with violent antisocial personality disorder and schizophrenia Presenter: Dr Elizabeth Zachariah, UK 10.30 An evaluation of the effectiveness of Enhanced Thinking Skills in improving the functioning of offenders with antisocial personality disorder traits Presenter: Dr Doyle, UK 10.45 The significance of protective factors in the assessment of risk Presenter: Dr Lennox, UK 11.00-11.30 (Foyer) Coffee and exhibition viewing Saphirs 1 & 2 11.30 11:30 12.00 13.00-13.45 (Foyer) SESSION 11 Research on Community Treatment Orders Chair: Prof Tom Fahy, Kings College London, Mrs Jill Locket, SLAM, London Coffee Evaluation of community treatment orders in the UK Professor Tom Burns, University of Oxford, UK Keynote Address - Involuntary Outpatient Commitment: The Data and the Controversy Professor Marvin Swartz, Duke University School of Medicine, USA Lunch and exhibition viewing Saphirs 1 & 2 13.45 14.15 SESSION 12: Issues in GermanForensic Psychiatry Chair: Dr Birgit Vollm, University of Nottingham, , UK Pathways to care and forensic services in Germany Professor Ruediger Mueller-Isberner, Medical Director, Haina Forensic Hospital European Court Case on preventative detention Professor Norbert Nedopil, Head of the Department of Forensic Psychiatry, University of Munich SESSION 13: A modern case of insanity Chair: Dr John Crighton, Edinburgh, UK 14.45 Clinical Case Presentation Dr Tim Exworthy, UK and discussants 16.00 Closing and valedictory remarks Dr Janet Parrott, Chair of the Forensic Faculty At the time of printing all information is accurate. We cannot be held responsible for any subsequent changes. PRESENTATION ABSTRACTS & BIOGRAPHIES (A-Z by presenter) The following materials have been provided with kind permission of the presenters. We hope you find the following speaker abstracts and biographies useful. Please feel free to approach speakers for any handouts which are not included here. Louis Appleby has recently been appointed as National Clinical Director for Health and Criminal Justice. The aim of his new post is to reduce mental illness in prisons and improve collaboration between mental health services and the criminal justice system. In his previous role as National Director for Mental Health in England he played a central role in plans to reform mental health services, bringing in a range of new services including home treatment, early intervention and assertive outreach teams, and mental health legislation. He led numerous initiatives including to reduce suicides and improve the physical environment of mental health wards. Since 1996 he has been Professor of Psychiatry at the University of Manchester and since 1991 a consultant psychiatrist in Manchester. He was awarded a CBE for services to medicine in 2006. PBR IN FORENSIC PSYCHIATRY: THE STORY SO FAR Dr Nick Broughton Payment by Results will underpin the future funding of services provided by NHS Trusts. It was initially introduced in the acute sector in 2003/4 and has now been extended to Mental Health Services. A 21 cluster model has been developed for working age adults. Each of these clusters will form the basis of currencies for commissioning services. Trusts are already allocating service users to these clusters, however, the national tariffs for the currencies have yet to be agreed. Work in Forensic Services is less advanced. Both a five cluster model developed by the London Programme Board and the 21 cluster model are currently being piloted in a number of forensic services. Dr Broughton will provide an overview of the developments to date and the likely next steps prior to the introduction of PbR in Forensic Mental Health services. Dr Nick Broughton Following graduating from Cambridge University, Dr Broughton completed his medical training at St Thomas‘s Medical School in London. He joined the St Mary‘s Psychiatric Training Scheme after completing house jobs before progressing to the West London Forensic Psychiatry Senior Training Scheme. He has worked in West London as a Consultant in Forensic Psychiatry for over ten years in a wide variety of settings, including prisons, a young offenders‘ institution, a specialist remand service and, most recently, a women‘s enhanced medium secure service. He has a particular interest in service development and has been involved in medical management for a number of years. He recently became Medical Director for West London Mental Health NHS Trust. Dr Broughton has sat on the Pan-London Service Line Reporting Programme Board since its inception in 2008 and last year joined the Department of Health‘s National Forensic & Challenging Behaviour Payment by Results Product Review Group - as such he has been closely involved in the development of PbR in forensic settings. Christopher D Byrne FRCP FRCPath PhD Professor Endocrinology & Metabolism The Institute of Developmental Sciences (IDS Building) (University of Southampton), MP 887 Southampton General Hospital Tremona Rd Southampton SO16 6YD The importance of the metabolic syndrome, also known as Syndrome X or the insulin resistance syndrome, was highlighted by Professor Reaven in the Banting Lecture at the American Diabetes Association annual scientific conference of 1988. Although this description brought the syndrome to scientific and clinical prominence, descriptions emphasising a clustering of inter-related cardio-metabolic risk factors can be traced back to the 1920s. The metabolic syndorme is characterised by a cluster of related biochemical and anthropometric features that include central obesity, glucose intolerance or diabetes, hypertension, and dyslipidaemia.The epidemic of obesity is largely responsible for the increasing prevalence of metabolic syndrome in the developed world. Since 2001 with the development of the National Cholesterol Education Program guidelines for diagnosing metabolic syndrome, simple pragmatic criteria have been available that can be applied in primary care across all continents. Although there is an on-going debate about the level of thresholds that should be applied to individual features of the syndrome, it is likely that with further research a consensus will be reached in the near future. These simple pragmatic criteria were revised in 2005 and again in 2009, with varying emphasis on the centrality of central obesity and the level of the thresholds that should be applied to glucose concentrations. In 2011, it is now clear that metabolic syndrome represents a condition of insulin resistance and ectopic fat accumulation associated with a proinflammatory and procoagulant phenotype. The syndrome is also strongly associated with other diseases such as non alcoholic fatty liver disease (NAFLD), polycystic ovary syndrome, type 2 diabetes and cardiovascular disease and often the metabolic syndrome features are present in people who present initially, with one of these diseases. The purpose of this presentation is to discuss the clinical and laboratory diagnosis of the metabolic syndrome and the relationship between metabolic syndrome and obesity, type 2 diabetes and cardiovascular disease. The presentation will also discuss the newer evidence showing than NAFLD is the key hepatic component of the metabolic syndrome and that NAFLD may be key to the increased cardiometabolic risk that occurs with the syndrome. Christopher D Byrne MB BCh PhD FRCP FRCPath Professor Endocrinology & Metabolism & Consultant Diabetologist University of Southampton & Southampton University Hospitals Trust Christopher Byrne trained as a physician and clinical scientist at Cardiff, Cambridge and Stanford Universities. After Medical Research Council clinical science fellowships he was appointed Professor of Endocrinology & Metabolism in Southampton and inaugural Director of the Wellcome Trust Clinical Research Facility. He was Director of the Clinical Research Facility for 5 years and is now a Principal Investigator within the Southampton NIHR Biomedical Research Unit in Nutrition, Lifestyle and Obesity. Christopher Byrne is an academic diabetologist with clinical and experimental research interests in the metabolic syndrome and non alcoholic fatty liver disease. His research involves understanding the developmental origins of metabolic syndrome and non alcoholic fatty liver disease, and the links between metabolic syndrome, non alcoholic fatty liver disease, type 2 diabetes and cardiovascular disease. His publications, include over a 150 peer reviewed authored papers and 2 books. Handouts follow: _________________________________ Slide 1 __ Metabolic syndrome: linking diabetes, cardiovascular disease and non alcoholic fatty liver disease Christopher D Byrne University of Southampton & Southampton University Hospitals Trust www.metabolicsyndrome.org.uk _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 2 _________________________________ Content • Definition in the context of type 2 dm • Metabolic syndrome and type 2 dm • Metabolic syndrome and morbidity and mortality • Insulin resistance and CV risk • Physical activity • NAFLD __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 3 _________________________________ Changing patterns of CVD risk factors __ _________________________________ __ 1984 Cholesterol Smoking Hypertension 2011 Central obesity Diabetes & MetS _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 4 _________________________________ What is type 2 diabetes? __ _________________________________ 9/10 Insulin resistant Marked glucose -cell intolerance dysfunction __ _________________________________ a progressive metabolic disorder –linked to beta cell failure and/or insulin resistance fpg>/= 7.0 mmol/l __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 5 _________________________________ What is metabolic syndrome? __ _________________________________ Insulin resistance +/- glucose intolerance +/- -cell dysfunction __ _________________________________ Ectopic fat accumulation & insulin resistance adversely affecting cardiometabolic risk factors (to increase risk of type 2 diabetes, cardiovascular disease and NAFLD) __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ Slide 6 Portrait of Daniel Lambert by Benjamin Marshall, 19th Century -so why do we need to decrease weight in people with MetS? _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ Denke M. N Engl J Med 2007;357:2526-2527 __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 7 Metabolic Syndrome Features 2009 Metabolic Syndrome Triglyceride Waist BP TG Glucose HDL > 94/80 cm 130/85 1.7mmol/l 5.6 mmol/l < 1.0/1.3 mmol/l BP HDL Cholesterol Fatty liver _________________________________ __ _________________________________ __ _________________________________ OBESITY Glucose intolerance Vascular inflammation & procoagulant phenotype __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 8 Criteria for Clinical Diagnosis of the Metabolic Syndrome Measure Categorical cut points Elevated waist circumference Population- and countryspecific definitions Elevated triglycerides (drug treatment for elevated triglycerides is an alternate indicator) >150 mg/dL Reduced HDL cholesterol (drug treatment for reduced HDL cholesterol is an alternate indicator) <40 mg/dL for males and <50 mg/dL for females Elevated blood pressure (drug treatment for elevated blood pressure is an alternate indicator) Systolic >130 mm Hg and/or diastolic >85 mm Hg Elevated fasting glucose (drug treatment for elevated glucose is an alternate indicator) >100 mg/dL Consensus statement International Diabetes Federation (IDF), the National Heart, Lung, and Blood Institute (NHLBI), the World Heart Federation, the International Atherosclerosis Society, and the American Heart Association (AHA) Circulation 2009; 120:1640-1645 _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 9 _________________________________ Risk factors for (central) obesity • • • • • • • • • Ageing but ? reason Sex, men and post menopausal women Ethnicity, South Asians – low lean body mass Socio-economic status - deprivation Low levels of physical activity – work/ leisure/ transport/ central heating Excessive calorie intake Secondary to e.g. hypothyroidism, glucocorticosteroids Smoking cessation/ other lifestyle change / depression Rarely genetics –commonest MCR-4R mutations (5% of people BMI > 30 kg/m2 middle aged adults) __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 10 Obesity, insulin resistance, type 2 diabetes and metabolic syndrome _________________________________ __ _________________________________ Insulin resistance Type 2 diabetes -cell dysfunction Metabolic syndrome: a disorder of ‘ectopic fat’ accumulation, insulin resistance (NAFLD) & cardio-metabolic risk __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 11 _________________________________ Diagnosis of diabetes 2010 • ADA for the first time said that HbA1c levels >6.5% are sufficient for a diagnosis of diabetes, while levels from 5.7% to 6.4% are a marker of "prediabetes" and indicate increased risk of both incident diabetes and cardiovascular disease American Diabetes Association. Standards of medical care in diabetes-2010. Diabetes Care 2010; 33 (suppl 1):S11-S61 __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 12 _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 13 Association between the metabolic syndrome and cardiovascular events and mortality: meta-analyses of longitudinal studies Covariates in risk model Study RR 95% CI McNeill 1.62 1.41 1.87 Sattar 1.41 1.05 1.90 Schillaci 1.73 1.25 2.38 Summary 1.54 1.32 1.79 MS Age Gender BP Lipids Glu Other x x x x x x 0.2 0.5 1 2 x x x x x x x x x x x x 5 _________________________________ __ _________________________________ __ _________________________________ Decreased risk Increased risk All studies excluded people with prevalent cardiovascular disease, and 1 study (45) excluded women. "Other" covariates included race (62), study site (in a multicenter study) (62), body mass index (45), C-reactive protein (45), creatinine (60), left ventricular hypertrophy (60), and cigarette smoking (45,60,62). The boxes represent the relative risk (RR) for individual studies and are proportional to their weight in the analysis, and the lines represent their 95% confidence intervals (CIs). The diamond represents the pooled RR, and its width represents its 95% CI. BP = hypertension or elevated systolic or diastolic blood pressure; Glu = fasting hyperglycemia;X = covariate included. __ _________________________________ Source: Gami et al J Am Coll Cardiol 2007;49:403-14 __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 14 Association between the MetS, CV events and mortality: meta-analyses of longitudinal studies Outcome Studies (N) RR 95% CI CV event 11 2.18 1.63-2.93 CHD event 18 1.65 1.37-1.99 CV death 10 1.91 1.47-2.49 CHD death 7 1.60 1.28-2.01 Death 12 1.60 1.37-1.92 __ Decreased risk 1 2 5 _________________________________ Increased risk The diamonds represent the pooled relative risk (RR) and 95% confidence interval (CI) for studies that assessed each outcome. Some studies assessed more than 1 outcome. CHD = coronary heart disease; CV = cardiovascular. Source: Gami et al J Am Coll Cardiol 2007;49:403-14 __ _________________________________ 0.5 N=172,573 people _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 15 _________________________________ ULSAM: *Death and Major Cardiovascular Events (HR, 95% CI) in the Different Groups End point Normal weight without metabolic syndrome Normal weight with metabolic syndrome Overweight without metabolic syndrome Overweight with metabolic syndrome Obese without metabolic syndrome Obese with metabolic syndrome Total death Referent 1.28 (0.90–1.82) 1.21 (1.03–1.40) 1.53 (1.19– 1.96) 1.65 (1.03– 2.66) 2.43 (1.81– 3.27) CV death Referent 1.77 (1.11–2.83) 1.44 (1.14–1.83) 2.19 (1.57– 3.06) 1.20 (0.49– 2.93) 3.20 (2.12– 4.82) Major CV events Referent 1.63 (1.11–2.37) 1.52 (1.28–1.80) 1.74 (1.32– 2.30) 1.95 (1.14– 3.34) 2.55 (1.82– 3.58) __ _________________________________ __ _________________________________ Circulation, Jan 2010; 121: 230 - 236 *1758 middle-aged individuals without diabetes in the Uppsala Longitudinal Study of Adult Men (ULSAM). During a median follow-up of 30 years, 788 participants died and 681 developed cardiovascular disease. Hazard models adjusted for age, smoking, and LDL cholesterol, metabolic syndrome __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 16 _________________________________ Diagnosis of diabetes 2010 __ • ADA for the first time said that HbA1c levels >6.5% are sufficient for a diagnosis of diabetes, while levels from 5.7% to 6.4% are a marker of "prediabetes" and indicate increased risk of both incident diabetes and cardiovascular disease _________________________________ __ _________________________________ __ American Diabetes Association. Standards of medical care in diabetes-2010. Diabetes Care 2010; 33 (suppl 1):S11-S61 _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 17 Incidence of New Diabetes and Hazard Ratio (95% CI) for Diabetes and Other Clinical Outcomes (14-Year Median Follow-Up), by Baseline Glycated Hemoglobin Level, in Nondiabetics <5.0% 5.0% to <5.5%c 5.5% to <6.0% 6.0% to <6.5% >6.5% Diabetes incidence (%) 6 12 21 44 79 Diabetesb 0.52 (0.40– 0.69) 1.00 1.86 (1.67– 2.08) 4.48 (3.92– 5.13) 16.47 (14.22– 19.08) CHD 0.96 (0.74– 1.24) 1.00 1.23 (1.07– 1.41) 1.78 (1.48– 2.15) 1.95 (1.53– 2.48) Ischemic stroke 1.09 (0.67– 1.76 1.00 1.17 (0.89– 1.53) 2.22 (1.60– 3.08) 3.16 (2.15–4.64 Mortality 1.48 (1.21– 1.82) 1.00 1.18 (1.04– 1.35) 1.59 (1.34– 1.89) 1.65 (1.31– 2.08) Parameter a. Adjusted for age, sex, race, low-density and high-density cholesterol levels, triglyceride level, body-mass index, waist-to-hip ratio, hypertension, family history of diabetes, education level, alcohol use, physical activity, and smoking status b. Defined as self-reported diagnosis of diabetes or use of antidiabetic medications c. Reference for hazard ratios Selvin E, Steffes MW, Zhu H, et al. Glycated hemoglobin, diabetes, and cardiovascular risk in nondiabetic adults. N Engl J Med 2010; 362:800-811 _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ Slide 18 _________________________________ __ • What is the relationship between insulin resistance and CV outcome? _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 19 Measures of tissue insulin sensitivity • 75g Oral Glucose Tolerance Test -NEFA suppression – to derive a measure of fat insulin sensitivity Belfiore F et al. Insulin sensitivity indices calculated from basal and OGTT-induced insulin, glucose, and FFA levels. Mol Genet Metab. 1998 Feb;63(2):134-41 • Euglycaemic Hyperinsulinaemic Clamp -Whole body glucose uptake & suppression of glucose production _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 20 Kaplan–Meier survival curves for subjects free from subsequent CHD events during 10.4 years of follow-up, for a) tertiles of insulin sensitivity index (Si), and b) tertiles of intact proinsulin at baseline. _________________________________ __ _________________________________ __ _________________________________ __ Diabetologia (2005) 48: 862-867 _________________________________ __ _________________________________ __ _________________________________ __ Slide 21 How can we improve insulin sensitivity? • Which aspect of „insulin sensitivity‟ are we trying to improve? – regulation of glucose metabolism? • Decrease hepatic glucose output, promote skm & adipose glucose uptake – regulation of vascular function? • Increase vasodilatation? • Increase microvascular nutrient exchange _________________________________ __ _________________________________ __ _________________________________ – regulation of triglyceride metabolism? • Decrease VLDL secretion • Decrease lipolysis of adipose TG to release free fatty acids? __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 22 Tissue microvascular dysfunction and metabolic syndrome Obesity Insulin Resistance Hyperglycemia Haemodynamics Vasodilatation ↓NO/AA Metabolism ↑Myogenic Response Impaired Microvascular Perfusion Dyslipidemia Inflammation Endothelial Integrity ↓Microvascular Density Inflammation and atherothrombosis Cytoskeletal Contraction Junctional Disorganisation Impaired Microvascular Solute/water Exchange Clough et al Diabetes 2009 Turzyniecka et al Diabetic Med 2010 Turzyniecka et al J Appl Physiol 2010 Clough et al Microcirculation 2010 _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 23 How can we improve insulin sensitivity? • „Lifestyle‟ treatment – What is it, how does it work & what exactly should we be recommending? • Drugs – What drugs, how do they work & what should we be recommending? • Bariatric surgery – What is it, how does it work and what should we be recommending? _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ Slide 24 How can we improve insulin sensitivity? • „Lifestyle‟ treatment _________________________________ __ _________________________________ – Physical activity/exercise – Diet & good nutrition __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 25 _________________________________ Energy balance __ • 50 extra calories a day leads to 2.4kg weight gain per year _________________________________ • Losing 1kg requires a deficit of about 7000 calories __ • Losing 0.5-1kg/week requires a deficit of 500-1000 calories/day __ _________________________________ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 26 Definitions: Physical activity/exercise Aerobic fitness Physical Activity Exercise _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ _ Slide 27 We know that physical activity is beneficial but……………. 1 person on the stairs ! _________________________________ __ _________________________________ __ _________________________________ __ ©2005. American College of Physicians. All Rights Reserved. _________________________________ __ _________________________________ __ _________________________________ __ Slide 28 What is wrong with this picture – why are they not on the stairs? _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 29 _________________________________ Managing CV risk • High absolute risk – Aggressive CV risk reduction treatment • LDLc treatment – statins targets QoF/NICE • Bp treatment „ABCD‟ - targets – Good nutrition – 5-10 fruits & veg – Tackling obesity – consider bariatric surgery – Improving PAEE – accumulation of 1 h „brisk walking‟ daily __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ Slide 30 _________________________________ Where else to intervene to reduce CV mortality? __ • Try and prevent/slow the progression of Type 2DM. _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 31 Incidence of New Diabetes and Hazard Ratio (95% CI) for Diabetes and Other Clinical Outcomes (14-Year Median Follow-Up), by Baseline Glycated Hemoglobin Level, in Nondiabetics <5.0% 5.0% to <5.5%c 5.5% to <6.0% 6.0% to <6.5% >6.5% Diabetes incidence (%) 6 12 21 44 79 Diabetesb 0.52 (0.40– 0.69) 1.00 1.86 (1.67– 2.08) 4.48 (3.92– 5.13) 16.47 (14.22– 19.08) CHD 0.96 (0.74– 1.24) 1.00 1.23 (1.07– 1.41) 1.78 (1.48– 2.15) 1.95 (1.53–2.48) Ischemic stroke 1.09 (0.67–1.76 1.00 1.17 (0.89– 1.53) 2.22 (1.60– 3.08) 3.16 (2.15–4.64 Mortality 1.48 (1.21– 1.82) 1.00 1.18 (1.04– 1.35) 1.59 (1.34– 1.89) 1.65 (1.31–2.08) _________________________________ __ _________________________________ Parameter a. Adjusted for age, sex, race, low-density and high-density cholesterol levels, triglyceride level, body-mass index, waist-to-hip ratio, hypertension, family history of diabetes, education level, alcohol use, physical activity, and smoking status b. Defined as self-reported diagnosis of diabetes or use of antidiabetic medications c. Reference for hazard ratios Selvin E, Steffes MW, Zhu H, et al. Glycated hemoglobin, diabetes, and cardiovascular risk in nondiabetic adults. N Engl J Med 2010; 362:800-811 __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 32 Glycaemic control and CV Mortality – Fasting glycaemic control reduces microvascular complications, and does not appear to contribute to reducing CV mortality. – Metformin reduces CV mortality (by improving endothelial function) and not by improving glycaemic control. – German Diabetes Intervention Study – the only interventional study to show improved CVD and all-cause mortality by controlling post-prandial glycaemia. _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ Slide 33 Ectopic fat accumulation: a link between insulin resistance, type 2 DM and vascular disease Triglyceride: obesity, insulin resistance and risk of type 2 DM Lipid metabolism: NAFLD, insulin resistance and type 2 DM Lipid metabolism NFB Foam cell formation Neointimal proliferation _________________________________ __ NEFA oxidation Glucose production _________________________________ Glucose uptake __ NEFA oxidation Insulin sensitivity Triglyceride accumulation: insulin resistance and risk of type 2 DM _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 34 Non-alcoholic Fatty Liver Disease (NAFLD) ….significant lipid deposition in the hepatocytes of the liver parenchyma in a patient without a history of excessive alcohol consumption _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 35 _________________________________ __ _________________________________ __ VACUOLATED NUCLEI _________________________________ __ H&E STAIN x 40 _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 36 Non-alcoholic fatty liver disease (NAFLD) definition • Liver injury – fat accumulation exceeding 5-10% by weight – fat laden hepatocytes by light microscopy • Similar to alcohol-induced liver injury • NAFLD • • • • Steatosis Steatohepatitis (NASH) NASH + extensive fibrosis NASH-induced cirrhosis _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ _ Slide 37 _________________________________ NAFLD: Spectrum of disease __ _________________________________ Non alcoholic fatty liver disease __ Steatosis (fatty liver) (20-30% of total) Steatohepatitis (NASH) (fatty liver+ inflammation) (2-3% of total) Cirrhosis Hepatocellular carcinoma _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 38 _________________________________ What causes/contributes to NAFLD? • • • • • Age Smoking Diabetes Met S/central obesity Altered early development (Bruce et al Hepatology 2009) __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 39 _________________________________ What is the relationship between physical activity, hepatic insulin sensitivity and hepatic fat? __ Physical activity _________________________________ r = 0.55, p = 0.01 Holt H et al. Diabetologia 2006 49:141-148 __ Insulin sensitivity _________________________________ Holt HB et al. Diabetologia 2007; 50: 1698–1706; __ r = -0.51, p = 0.05 (liver) r = - 0.53, p=0.04 (muscle) r = - 0.52, p=0.04 (fat) Holt HB et al. Diabetologia 2007; 50: 1024–1032. Hepatic fat _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 40 _________________________________ Association between NAFLD and prevalent CVD in type 2 diabetic adults with and without NAFLD UN-ADJUSTED O.R. P < 0.001 AGE-, SEX-ADJUSTED O.R. P < 0.001 MULTIPLE*-ADJUSTED O.R. P < 0.001 METABOLIC SYNDROME and MULTIPLE*ADJUSTED O.R. (n=2,392) 0 __ _________________________________ __ P = 0.03 0,5 1 1,5 2 2,5 3 _________________________________ Logistic Regression; OR (95% CI) Data are expressed as odds ratios ( 95% confidence intervals). *The multiple adjustment reported in the third and fourth bars was as follows: age, sex, BMI, smoking status, diabetes duration, HbA1c, LDL cholesterol and current use of medications (hypoglycaemic, anti-hypertensive, lipid-lowering or anti-platelet drugs). Targher et al Diabetes Care. 2007 Aug;30(8):2119-21. __ _________________________________ __ _________________________________ __ _________________________________ Slide 41 _________________________________ Fatty acid exposures could affect: __ • Insulin sensitivity • Hepatic fat metabolism (synthesis/oxidation) – via SREBP1c, _________________________________ -> Fatty acids could affect the risk, severity and progression of NAFLD _________________________________ __ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 42 _________________________________ Saturated fatty acids appear to: • • • • __ Insulin sensitivity Hepatic fat synthesis _________________________________ Hepatic inflammation __ -> Saturated fatty acids could increase the risk, severity and progression of NAFLD _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 43 _________________________________ __ Much recent interest in the possible protective effects of omega-3 (w-3; n-3 ) fatty acids _________________________________ ‘fish oils’ _________________________________ __ __ _________________________________ __ _________________________________ __ _________________________________ Slide 44 Found in seafood, especially oily (fatty) fish, fish oils, liver oils, algal oils, pharmaceutical preparations (Omacor) .. … _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 45 _________________________________ „Fish oil fats‟……..these 2 fatty acids are present in „fish oil‟ and are present in very high concentration in OMACOR COOH H3C Eicosapentaenoic acid EPA __ _________________________________ 20:5w-3 __ H3C COOH Docosahexaenoic acid DHA 22:6w-3 NB. Fish oils may contain other unfavourable compounds e.g. mercury Fish oils are not pure preparations but OMACOR is just EPA and DHA _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 46 Marine w-3 fatty acids (contained in fish oils) • • • • Insulin sensitivity (some studies only) Hepatic TAG synthesis – via SREBP1c Hepatic fatty acid oxidation – via PPAR-a Systemic inflammation – via NFB and PPAR-g (? Hepatic inflammation) – also eicosanoid and resolvin mediated effects -> w-3 fatty acids could decrease the risk, severity and progression of NAFLD _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 47 Wessex Evaluation of fatty Liver and Cardiovascular markers in NAFLD with OMacor thErapy: WELCOME study funded by the National Institute for Health Research (UK) and Diabetes UK _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 48 _________________________________ The WELCOME Study evaluates the effects of purified w-3 fatty acids (OMACOR 4 g/d) on serum biomarkers, cardiovascular risk markers and liver fat in a randomized placebo controlled trial in patients with NAFLD __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 49 _________________________________ __ Schedule, visits and timescale Visits 1 & 2 4 5 _________________________________ 6 & 7 (+/- 8) Purified w-3 fatty acid EEs 4 g daily (n =50) Placebo n=50 -4 0 4-6 10-12 15-18 Months __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ Slide 50 _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 51 _________________________________ Acknowledgements Southampton University Magdalena Turzyniecka King’s College London/ Edinburgh/Cambridge/ Surrey Lucilla Poston, Josie McConnell Kim Bruce JJ Valletta & Andy Chipperfield Marco Argenton, Margot Umpleby, Nick Wareham, Ulf Ekelund, Lucinda England Sarah H Wild Mark Hanson _________________________________ __ Felino Cagampang Dyan Sellayah _________________________________ Geraldine Clough Priya Ethirajan Graham Burdge Mohamed Ahmed Helen Holt, David Philips __ __ Funding Bodies 51 _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 52 The Welcome team Christopher Byrne Philip Calder Geraldine Clough Loke Bhatia Debbie Smith Norma Diaper Gillian Wise Sanchia Triggs Bridget Clancy Keith McCormick Kate Nash Nick Curzen BRU Nutrition/Lifestyle staff CRF staff PIC centres in Bournemouth, Poole, Winchester, IOW, Basingstoke Portsmouth, Collaborators in Oxford: Leanne Hodson and Keith Frayn Collaborator in University of Surrey: Margaret Umpleby Collaborator in University of Nottingham Neil Guha _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ ________________________________ Mass and Spree Killers: An Anaylsis of Extreme Violence Professor Jack Levin, Northeastern University Most criminologists recognize three types of multiple homicide: mass murder, spree killing, and serial murder. Thanks to sensationalized accounts of sadistic sexual attacks, the emphasis in popular culture has been mainly on serial murder rather than the other two types. Yet the distinctions among types of multiple homicide frequently break down, making them less than useful for the purposes of research. Decades earlier, it was widely believed that only the body count separated homicide from multiple homicide. We now know that mass and spree killers differ from their single-victim counterparts in a number of important characteristics. Moreover, unlike cases of murder generally (really, manslaughter), mass killers are methodical and selective, usually planning their crimes far in advance. They almost always have mental health and situational issues hardly found in other murderous perpetrators. The profile of a mass killer may help to explain, but it hardly predicts. The false positive problem, frequently an obstacle to predicting rare events, plagues the study of mass, spree, and serial killers. Our warning signs apply not only to perpetrators of multiple homicide but also to numerous healthy and decent people. Professor Jack Levin is the Irving and Betty Brudnick Professor of Sociology and Criminology at Northeastern University in Boston, where he co-directs its Center on Violence and Conflict. He has published 30 books and numerous journal articles and newspaper columns, primarily in the areas of multiple homicide (mass, spree, and serial) and hate crimes. Levin was recently the recipient of the American Sociological Association‘s Award for the Public Understanding of Sociology. He has given numerous keynote addresses to professional, academic, and community organizations in countries around the world. TREATMENT OF SEXUAL OFFENDING Ruth E Mann, PhD, National Offender Management Service This presentation will summarise recent literature about criminogenic and protective factors for sexual offenders and how these might be identified. Dr Mann will suggest what the major targets for treatment should be, and will consider why the targets of victim empathy and taking responsibility for offending may need less attention in treatment than previously thought. She will compare the major offender rehabilitation models and will offer suggestions for a fully bio-psycho-social approach to treatment, which expands beyond the more traditional approach of psychologically-focused treatment. Dr Mann will also discuss the importance of the wider residential, social and cultural context and how the attitudes of others can support or derail treatment. Dr Ruth Mann is a Consultant Forensic Psychologist who works for the National Offender Management Service (NOMS), where she is responsible for the treatment of sexual offending across prison and probation services. She is also responsible for NOMS‘ programme of rehabilitation research. Ruth has worked in the field of sex offender treatment since 1987, originally as a practitioner and for the last 15 years in a policy/administrative position. Ruth has published over 50 articles and book chapters on topics related to sex offender assessment and treatment, is on the editorial board of Sexual Abuse: A Journal of Research and Treatment, and in June 2010 won the British Psychological Society Division of Forensic Psychology Senior Award for her contribution to forensic psychology in the UK. Handouts follow _________________________________ Slide 1 __ Treatment of Sexual Offending Ruth E Mann, PhD National Offender Management Service, England & Wales Faculty of Forensic Psychiatry Annual Meeting Berlin, February 2011 _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 2 _________________________________ Background __ National treatment in English & Welsh prisons since 1992 Followed by national treatment in probation settings Creation & re-organisation of National Offender Management Service National joint treatment planned for 2011 _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 3 _________________________________ Major Rehabilitation Models __ Relapse Prevention _________________________________ Marlatt, Laws Risk Need Responsivity Model Andrews & Bonta Good Lives Model Ward __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ _ Slide 4 _________________________________ Relapse Prevention Model Developed from clinical observation Offenders want to give up offending but lack the skills to do so Recognition and Management of Risk Acknowledgement of motivation In practice, very avoidance focused __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 5 _________________________________ Risk Need Responsivity Model Empirically based model Risk principle Need principle Responsivity principle __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 6 _________________________________ Good Lives Model Theoretically developed Offending as an attempt to secure life‘s goods E.g. intimacy, inner peace, sexual satisfaction, autonomy, mastery Strong appeal to clinicians __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ _ Slide 7 _________________________________ Which model? RP was not designed to be avoidance focused RNR appreciates the importance of working positively with offenders GLM is experienced more positively but RNR leads to better recognition of risk factors RNR has strongest empirical base __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 8 Other characteristics of evidence based programmes Have a printed manual Select and train staff carefully Staff understand and can articulate the theoretical model of the program (the ―Model of Change‖). _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 9 _________________________________ __ Treatment Targets _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ _ Slide 10 _________________________________ Criminogenic needs Sexual preoccupation Any deviant sexual interest Offence supportive attitudes Emotional congruence with children Lack of intimacy Lifestyle impulsivity Poor cognitive problem solving Resistance to rules Grievance & hostility Negative social influences (Mann, Hanson & Thornton, 2010) __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 11 _________________________________ Protective factors Healthy sexuality Constructive occupation (including employment) Motivation to desist Hope Agency Positive identity An intimate relationship Healthy social support (a place within a group) Sobriety Being believed in (Maruna, 2010) __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 12 _________________________________ Readiness targets? Denial? __ _________________________________ Resistance or low motivation __ Ability to handle groupwork _________________________________ (Mann, Ware & Barnett, 2010) __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 13 Current practice (US) >80% programmes (McGrath et al, 2010) Offense responsibility Not criminogenic Victim empathy Not criminogenic Intimacy skills Criminogenic Social skills Not criminogenic Slide 14 Current practice (Canada) >80% of programs Intimacy skills Criminogenic Victim empathy Not criminogenic Emotional regulation Criminogenic _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 15 Current practice (England/Wales prison) Attitude reconstruction Victim empathy Self regulation (emotional regulation, intimacy, problemsolving) Weakly criminogenic Not criminogenic Criminogenic _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 16 _________________________________ Not doing enough of…? Sexual self regulation Sexual interests Offence supportive attitudes Impulsivity Problem solving & coping Grievance, hostility and callousness Social support Intimacy support Employment or constructive use of time __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 17 _________________________________ Doing too much of…? Offense responsibility Victim empathy Social skills __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 18 _________________________________ Accepting Responsibility Often assumed to be equivalent to making a full confession Need for a confession may be intuitive or emotional rather than rational Failure to confess = refusal to accept sexual offender identity? May be associated with desistance __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 19 An alternative to confessionoriented treatment Focus on taking responsibility for the future More prevalent in desisting offenders (Maruna, 2001) _________________________________ __ _________________________________ __ _________________________________ (Ware & Mann, in preparation) __ _________________________________ __ _________________________________ Slide 20 _________________________________ Victim empathy __ Rehabilitation, punishment or correctional quackery? _________________________________ Rehabilitation – offenders report VE to be important Punishment – offenders report VE to be distressing Correctional Quackery – lack of coherent rationale for VE; lack of VE not an established risk factor __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 21 _________________________________ An alternative to Victim Empathy __ Enable offenders to overcome obstacles to empathy _________________________________ Ability to experience emotion Perspective taking (theory of mind) Menschenliebe Situational factors Management of personal distress, shame, stress (Mann & Barnett; Barnett & Mann; 2010) __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 22 _________________________________ __ Treatment Methods For a bio-psycho-social programme _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 23 _________________________________ ―Biological‖ methods __ Medication (anti-androgen, SSRI) (Grubin, 2009) Treatment that is sympathetic to neuropsychology of offenders (Creeden, 2009) Eyebrows-down approach (Visual, audio, kinasthetic) Repetitive skills practice Real life integration _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 24 _________________________________ Case examples Mr A Experienced persistent neglect as a child Is impulsive, often emotionally driven and struggled at school Finds it hard to articulate his inner world Suspicious of others __ Mr B Well educated Had a loving childhood Likes to discuss, analyse, read and write. Enjoys psychometric testing sessions Easily trusts others _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 25 _________________________________ Cognitive-Behavioural Methods Standard CBT – adjusting thoughts as a way of managing behaviour Attitude change – related to attitudinal risk factors (offence supportive attitudes, hostile attitudes, beliefs that hamper intimacy and trust). Skills practice, behavioural experiments, etc. __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 26 _________________________________ Social methods __ Working positively with those engaged in risk management Encouraging social protective factors _________________________________ Employment, accommodation, hobbies, constructive daily & weekly routine Enhancing social support Improving relationship skills Filling gaps for those who lack support (COSA) Maintaining family ties __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 27 _________________________________ Case examples Mr C Employed Evenings spent with brother, girlfriend or mother One evening alone per week ―me time‖ Weekly schedule indicated busy life, constructive activity and regular routine __ Mr D Unemployed Lack of social contact Mainly watching TV Remained inside for days at a time Irregular sleeping and waking hours _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 28 _________________________________ Basic Therapist Competencies __ Understanding normative behaviours and theoretical models of sexual deviance Socratic questioning Effective use of behavioural techniques such as reinforcement, extinction and modelling Generalisation of alternative thinking and behaviour outside the treatment environment Understanding and using group process Working with a co-therapist _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 29 _________________________________ Advanced Therapist Competencies Expert therapeutic skills Interpersonal skills Understanding and accepting the client Using positive language Instilling hope for change Working collaboratively with the client Personal resilience (Fernandez & Mann, 2009) __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 30 _________________________________ Four essential therapist skills __ _________________________________ Reinforcing Directive Warm Genuine __ _________________________________ (Marshall, 2005) __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 31 _________________________________ __ Treatment Context _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 32 _________________________________ The social environment __ Offenders report that this affects their decision to engage in treatment more than other factors _________________________________ Views of family and friends Views of professionals Extent to which sex offenders are stigmatised (Mann, 2009) __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 33 _________________________________ The group environment Mixed group and individual sessions work best (Schmucker & Losel, 2009; Ware et al, 2009). Effective group environment features: Cohesive, well organised Encouraged open expression of feelings Produced a sense of group responsibility Instilled hope in members Detrimental group environment features: Over controlling leaders (Beech & Fordham, 1997) __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 34 _________________________________ Society Extent to which sex offenders are stigmatised Extent to which communities take responsibility for managing risk (COSA) Extent to which policy makers seek evidence to form or to justify policies __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 35 _________________________________ __ Conclusions _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 36 _________________________________ Treatment works? __ Overall, treatment seems to reduce recidivism (Schmucker & Losel, 2010) RNR principles are upheld _________________________________ (Hanson et al., 2009) Not all programmes work, and there are few studies of high quality design Major RCT of sex offender treatment did not show a treatment effect (highly structured RP programme) (Marques et al, 2005) Treatment unlikely to work in isolation __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 37 The best chance for treatment to work? When there is a clear model of change When RNR is part of the model of change When the aims of treatment are understood and supported by people other than the programme staff When evidence wins over intuition _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 38 _________________________________ __ Thank you for listening [email protected] _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Forensic Psychotherapy in the Dutch TBS-provisions: effective by what means? Hjalmar van Marle, MD PhD, psychiatrist, psycho-analyst. Full Professor of Forensic Psychiatry Erasmus University Medical Centre and School of Law Erasmus University, Rotterdam, the Netherlands. Psychotherapist/supervisor forensic psychiatric out-patient clinic Het Dok Rotterdam. The Dutch TBS-detention measure, an Entrustment Act, has been implemented since 1928 for those offenders who are held diminished responsible for their acts. In practice that means that TBS has been sentenced most of the time for dangerous offenders with a personality disorder, which played a role in the enactment of the often violent offences. The last two decades more and more mentally ill offenders have become TBS-detainees as their aggressive behaviour was not to handle in the general psychiatric hospitals anymore. Their presence now is about 20% of the total TBS-population. The TBS-hospitals work according Programmes of Care, national established by the EFP (Centre of Expertise for Forensic Psychiatry in Utrecht), but locally adjusted to the treatment philosophy of the hospital involved: for psychotic patients, personality disordered patients, sex offenders, and long-stay patients. Treatment in the TBS-hospital is originally the combination of socio-therapy and psychotherapy, as the patient-staff relationships on the wards are the emotional engine for the psychotherapies, group and individual. Individual psychotherapy is indicated when a patient is not able to profit from the group psychodynamics only, which is often the case with narcissistic, psychopathic and paranoid personalities. The results of psychotherapy then should be visible by the staff members on the ward, and could be further developed towards diminishing the assessed risk factors. Best evidenced forensic psychotherapies are Cognitive Behaviour Therapy, Dialectic Behaviour Therapy, Scheme Focussed Therapy, and Functional Family Therapy for juvenile delinquents. Supervision regarding the therapeutic relationship remains necessary. Non-specific treatment factors like support play an important role. Structured professional riskassessment (HCR-20 and the Dutch version HKT-30) is mandatory; it evaluates the broader scope of riskfactors, among them the more clinically relevant dynamic risk-factors. Research on the effectiveness of the different kinds of psychotherapy is very difficult as they are never given in an isolated position. Staff and psychotherapists are working with the same focus on high-risk behaviour, and within the individual treatment program also other therapeutic activities will take place next to the education of rehabilitating skills. Other severe confounders are the maximum security ‗high pressure‘ environment with the risk of apparent adaptation (by levelling all behaviour) and the safety-centered interventions of the Ministry of Justice: huge (mediating or moderating) influences but hardly to measure. An extra problem in forensic psychotherapy is that the primary focus is on personal functioning in the hereand-now situation, while the criterion: prevention of re-offending will be met only after years. Future situations in the community cannot be taken into account, including substance abuse. The rate of recidivism after TBS is 10 to 20 percent, more to 10 for violent offenders and more to 20 for the sexual offenders. About 10 percent of the TBS-detainees will not leave the hospital, so called long-stay. Marvin S. Swartz Involuntary Outpatient Commitment: The Data and the Controversy Abstract Court-ordered community mental health treatment is among the most contested issues in mental health treatment. While most United States jurisdictions have statutes nominally authorizing involuntary outpatient commitment—a legal order to adhere to prescribed treatment in the community—until recently few US states made substantial use of these laws. With the enactment of involuntary outpatient commitment (OPC) statutes in New York in 1999, in California in 2003, and in Florida, Michigan, and West Virginia in 2005, and the tragic deaths at Virginia Tech in the wake of a failed outpatient commitment order, policy interest in OPC in the US has increased. In addition, interest in community treatment orders in the UK, Canada and Europe has also grown. This presentation will review the data and controversy about these forms of courtordered treatment with a focus on a recently completed evaluation of New York State's Assisted Outpatient Treatment program. Marvin S. Swartz, M.D., is Professor and Head, Division of Social and Community Psychiatry and Executive Vice Chair in the Department of Psychiatry and Behavioral Sciences at Duke University Medical Center. Dr. Swartz's major research interest is in examining the effectiveness of services for severely mentally ill individuals. He is former a Network Member in the MacArthur Foundation Research Network on Mandated Community Treatment and Principal Iinvestigator of the NY State evaluation of Assisted Outpatient Treatment in NY. He also serves as Co-PI of a study of the costs of mental health treatment in criminal justice settings. He serves as Co-PI with Jeffrey Swanson of a NIMH study examining the effectiveness of Psychiatric Advance Directives. Dr. Swartz is also Director of the National Resource Center on Psychiatric Advance Directives. WORKSHOP SUMMARIES & HANDOUTS Workshop 1 Adolescent and Young Adults Forensic Services Paul Monks, Heidi Hales, Enys Delmage & Ash Roychowdhury “The Trouble with Teenagers…challenges of diagnosis and transitional care for mentally disordered young offenders” The workshop has the following educational goals: 1) 2) 3) 4) 5) To give the audience an understanding of adolescent forensic services in the UK To highlight the importance of effective transitions for a highly complex group To discuss the challenges of effective transitional care from national to regional or local providers To contemplate ways of managing these challenges via group discussion To discuss and share ideas about what treatments should be provided and what outcomes should be achieved for this age group FORMAT: The first 45 minutes of the workshop will be led by Drs. Monks, Delmage and Hales and will be focussed on discussing the epidemiology to give the audience a representative description of the scale of needs. Trends will be discussed regarding types of offending and common mental disorder presentations to services, and the common pathways to secure hospital care. There will also be a discussion of the national picture in terms of secure hospital service provision for those aged 13-18, in addition to a review of the areas of currently unmet need. The diagnostic challenges will make up part of the discussion, as well as consideration of the general developmental milestones that young people go through, and how this can impact upon their mental health management. There are specific issues related to the treatment of young people which hinge on these milestones, namely funding arrangements which can radically alter when the young person reaches 18 years of age. A further discussion will follow regarding the subdivisions within adolescent forensic populations of those 16 year olds who would benefit from placement in an adolescent forensic service until their early 20s and those 16 year olds who would benefit from a move to a transitional service at the age of 18. Following this, the audience will be asked the following question to consider over a period of 20 minutes: ―What should a transitional service for adolescent mentally disordered offenders look like?‖ The audience will be tasked with considering the rationale, structure and philosophy of a transitional service for young mentally disordered offenders (aged 18-26) and whether this group deserve special consideration and a bespoke service to manage their specific needs. We will also consider outcome measures and national guidance from New Horizons, the Care Quality Commission and the National Institute for Health and Clinical Excellence, as well as the implications of the Bradley Report as applied to this population. Dr. Roychowdhury will sum up in the final 25 minutes and will discuss common themes from the workshop, and the challenges he sees transitional forensic services facing both now and in the future. _________________________________ Slide 1 __ The Trouble With Teenagers… Challenges of Diagnosis and Transitional Care for MDYOs _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 2 _________________________________ Learning Objectives 1 2 3 • To consider the service needs of adolescent MDYOs when transitioning from C&A to Adult services • To consider different models of transition planning • To discuss ways in which Adolescent and Adult forensic services can work together to effect smooth and successful transitions __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ Slide 3 Adolescent forensic services – at the interface between CAMHS and adult forensic services, local authority and juvenile criminal justice system Community Adolescent Forensic CAMHS Adolescent Forensic Adult Forensic Services _________________________________ __ Youth Offending Teams (United Kingdom) / Young Person’s Probation (Republic of Ireland) _________________________________ NCG (NHS) adolescent forensic inpatient units (in England and Wales) or adolescent inpatient units (Scotland and Ireland) Independent secure inpatient units Voluntary sector services __ Inreach into Secure Training Centres or Youth Offender Institutions (prisons for juveniles) _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 4 _________________________________ Epidemiology Prevalence of mental health problems for young people in contact with mental health services: 25-81% (increased if in custody) Conservative estimate: x3 higher than agematched controls 62% of adolescent female serious offenders and 35% of adolescent male serious offenders have histories of abuse, abandonment or neglect __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 5 _________________________________ Developmental needs of adolescents Separation from their parents / care-givers socially and emotionally – but ongoing need for their support and guidance; Parental involvement (positive or negative) has great influence on their mental state Development of own identity; Development of capacity for intimacy; Disruption of education / training may harm future prospects. __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 6 _________________________________ Service needs of adolescents Young people are more impulsive and energetic than adults Young people require more containing care and adult input to feel secure (attachment theory) Managing young people requires liaison with many agencies. Managing young people requires work with parents. Prodromal stage more commonly seen emerging in adolescence. Medication used in adult patients may have increased risks in young people. Family therapy has been shown to be a more effective in young people than adult patient for certain disorders (eating disorder, conduct disorder) whereas adult patients respond more to individual therapy. __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 7 _________________________________ __ Why are transitions important / difficult? _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 8 _________________________________ Different systems ... Adolescent __ Adult adult adolescent parents / carers school/ college community nuclear family – spouse / children work/ day centres community _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 9 _________________________________ Different Agencies CAMHS MAPPA __ Paeds _________________________________ CMHT Education MAPPA Voluntary Youth Work Education Welfare Officer Adolescent Connexions Back to Work organisations GP Adult Social Services Vulnerable Adult Social Services YOI YOT Prison Secure Children‟s Home Probation __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 10 _________________________________ Different diagnoses Child Adult Neurodevelopmental – ADHD / Autistic Spectrum Autistic Spectrum Disorder Learning Disability Learning Disability Emotional Disorder Affective Disorder Psychotic Disorder Psychotic Disorder Adjustment Disorder Complex PTSD Emergent Personality Disorder PTSD Personality Disorder __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 11 _________________________________ Diagnostic Issues Emergent Personality Disorder vs. Conduct Disorder/Mixed Disorder of Conduct and Emotions Conduct Disorder vs. Attachment Disorder vs. ASD Mental Illness vs. Mental Disorder Psychosis vs. Acute Stress Reaction in YOI __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 12 _________________________________ Many transitions across different ages CAMHS Adolescent Forensic General Adult Adult Forensic Child and Family Social Services 16-18 Leaving care School 16 College Home varying Independence CAMHS funding 18 Adult funding YOi 21 Adult prison __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 13 _________________________________ Funding Issues Adolescent services are more expensive than adult services More staff Education Financial provision for adolescent Safe Guarding More agencies to liaise with Family involvement __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 14 Case Example (1) – Who is the accepting team Known to CAMHS Admitted from LASCH / YOI No specified address now Who is the local CMHT / Forensic Team to transfer to _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ _________________________________ __ Slide 15 _________________________________ Case example (2) At what age should we transfer 18 year olds – settled in current unit __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 16 _________________________________ Case example (3) How do we effect a smooth transfer Many have PD Should have slow / planned transfer However, beds come up suddenly __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 17 _________________________________ Meanings • Transition can have several overlapping meanings: • The social transition from adolescent roles to adult roles. • The transition in presentation from adolescent mental disorders to adult. • The transitions from adolescent secure care and its approach to adult secure services. • Transition from adolescent criminal justice and legal processes to adult equivalents. • Transition as a reflection of ongoing emotional, social and cognitive development in this age group. • Due to the above, providing effective care to this age group can be very challenging. __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ Slide 18 _________________________________ • • • • • • Why Young Adults? Variable Maturity : many young adults exhibit developmental levels more characteristic of far younger people. Brain development continues into the mid to late 20s, affecting reason, judgement and impulse control, and young people with the most troubled or traumatic childhoods often take longer to mature. A critical age for getting it right: the peak crime age is 19; young adults are the most likely age group to desist from crime. (23) Peak for onset of the major psychotic disorders such as schizophrenia and bipolar illness in males, head injuries, the peak of alcohol and drug abuse, and the peak association between drugs use and violence all occur in this age group Are adult forensic services able to deliver specialist assessments (e.g. For ADHD, autism) and early intervention approaches to psychosis, PD? . __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 19 _________________________________ Social Context • • • • • • • • Society has changed: The age at which someone becomes a fully independent adult in society is much later now than it was in earlier decades. The criminal justice system‟s approach (and adult forensic?) to 18-24 year olds is out of step with cultural and social norms of transitions to adulthood Young Adults have complex needs: Mentally disordered offenders frequently have few or no educational qualifications, and no experience of work. They also suffer from high levels of mental ill health, and alcohol and drug problems. In the transition to adulthood, support from care services, CAMHS, YOTs and childrens services disappear. How good are current adult forensic services at addressing social exclusion? __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 21 _________________________________ Managing the Issue • Other Departments are moving in the right direction: the DWP has policies aimed specifically at young people aged 18-24, on account of their specific need and life stage, recognizing that there is a complex tangle of benefits, support and penalties throughout the transition to adulthood. • Poor Transitions to Adulthood impact on the next generation: at least ¼ of young men in prison are fathers; most young women in prison are mothers. Getting it right by maintaining family relationships can help people move away from crime __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 22 _________________________________ Workshop Question: “What should a transitional service for adolescent mentally disordered offenders look like?” Rationale Structure Philosophy Age range Arguments for and against __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ Slide 23 _________________________________ Common Themes from the Workshop __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 24 Challenges from one who knows… Service development and internal challenges to overcome External challenges The future, Big Society and GP commissioners… _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Workshop 2 Relational Security Paul Gilluley, Bradley Hillier and James Tighe The Department of Health issues ―See. Think. Act.‖ in 2010 to improve relational security within secure mental health services. This workshop will discuss the background of why there was a need to improve relational security within services. The approach to improve relational security through, ―See. Think. Act.‖ Will be discussed. The background to relational security will be explored and the development of standards within the Quality Network.. Methods of measuring relational security will be discussed. Objectives 1. To describes the background for the need for an improvement in relational security. 2. To understand relational security and ―See. Think. Act.‖ 3. To get an idea of practical experience of how this has changed services approach to security. 4. To look at how we can measure relational security. Presenters - Dr Paul Gilluley, Chair Advisory Group for the Quality Network Dr Bradley Hillier, SpR in Forensic Psychiatry Jim Tighe, Bracton Centre. Format Brief presentation of the background of the work and initial evaluation carried out. Some time for audience to share how they have used programme within their service. Discussion of high level indicators proposed for the measurement of relational security within services. Workshop 3 Substance misuse interventions in forensic services Niamh Power, Julia O‘Connor and Alex Whale Summary not available at time of going to press. Workshop 4 Mentalization* and group reflective practice** in the management of forensic personalitydisordered patients *Jessica Yakeley and Andrew Williams: Portman Clinic, Tavistock and Portman NHS Foundation Trust: Gill McGauley: Broadmoor Hospital, West London Mental Health Trust and St George‘s University of London. **Roberta Babb, John Canning and Cleo Van Velsen: Millfields Unit. East London NHS Foundation Trust. This workshop presents two linked treatment approaches to working with forensic personality-disordered forensic patients. First, the findings, one year on, of a pilot project offering mentalization-based treatment (MBT) to violent men with a diagnosis of antisocial personality disorder (ASPD) in an out-patient setting. It is part of a multi-site research project co-ordinated by Anthony Bateman and Peter Fonagy aiming to evaluate whether patients with ASPD can benefit from MBT. Second, the use of a tool, the Interface of Meaning and Projection Formulation (impF), will be demonstrated. The impF has been specifically designed for facilitating group reflective practice for clinical teams working with forensic personality-disordered inpatients. NICE guidelines on ASPD were welcomed for legitimizing treatment for this group of people who are often both treatment-rejecting and treatment-resistant. However, the narrow range of treatment recommendations for adults with ASPD highlighted the need for more research into effective treatments for this complex and costly disorder. MBT is a psychoanalytically-based treatment approach that has been developed by Bateman and Fonagy (2004) for patients with borderline personality disorder (BPD). Recently, there has been increasing interest in the forensic field in the application of MBT to forensic patients with a diagnosis of ASPD. Like BPD, ASPD can be understood as a disorder of attachment in which genetic precursors interacting with early environmental adversity result in the abnormal development of mind in the areas of affect regulation, impulse control and ability to mentalize. In the first half of this workshop we will present research data showing that ASPD patients have both disordered attachment patterns and an impaired capacity to mentalize, as measured by their Reflective Function. We will then describe our treatment approach, the methodology and results to date of our pilot project. Treatment efficacy for personality disordered forensic patients is dependent upon the containment, cohesiveness and the collective reflective function of the staff team. The second part of this workshop demonstrates the fundamental need for group reflective practice for clinical teams working with personalitydisordered offenders. The impF process allows the different emotional experiences of individuals/disciplines who work with patients to be shared and become meaningful for the whole team. Without this, psychiatric teams can come to resemble the fragmented mind of the patient, and differences between clinical team members can easily slip into opposition, with individuals loosing their ‗psychological bearings‘ i.e. being caught up in a patient‘s re-enactment of previous trauma. The impF process creates a different reflective practice space which goes beyond the evacuating of unpleasant feelings. Clinical examples will be presented which show the link between the impF and the treatment resistant patient enhancing their own reflective function. Learning objectives: After attending this workshop participants will be able to: - Understand the concept of mentalization and its relevance to ASPD patients. Describe the MBT treatment approach for ASPD and how it links to the aetiology of the disorder. Understand the importance of group staff reflective practice within PD services. Describe the impF process and how it links to treatment resistant PD. Roberta Babb: Chartered Clinical Psychologist, Millfields Unit. East London NHS Foundation Trust. John Canning: Modern Matron, Millfields Unit. East London NHS Foundation Trust. Gill McGauley: Consultant Psychiatrist and Reader in Forensic Psychotherapy, Broadmoor Hospital, West London Mental Health Trust and St George‘s University of London. Cleo Van Velsen: Consultant Psychiatrist in Forensic Psychotherapy Millfields Unit. East London NHS Foundation Trust. Andrew Williams: Consultant Psychiatrist in Forensic Psychotherapy, Portman Clinic, Tavistock and Portman NHS Foundation Trust Jessica Yakeley: Consultant Psychiatrist in Forensic Psychotherapy, Portman Clinic and Director of Medical Education and Associate Medical Director, Tavistock and Portman NHS Foundation Trust Workshop 5 New Versus Old Diminished Responsibility Nigel Eastman, Sathana Gunasekaran and Nuwan Galappathie Description The Coroners and Justice Act 2009 has replaced the partial defence to murder of ‗diminished responsibility‘, as defined under the Homicide Act 1957, with a significantly different defence, applicable to killings committed from 4 October 2010. The workshop will compare ‗new‘ and ‗old‘ diminished responsibility, specifically from the perspective of the medical expert. The changes introduced by the new Act will be explained, including uncertainties in terms of how the Court of Appeal may interpret particular aspects of the new provisions. Such uncertainties relate both to interpretation of the substantive defence and to the relative roles of expert and jury. Four vignettes amounting to ‗paradigm cases‘ of potential diminished responsibility will then be provided to participants, who will be asked to consider these under both the old and new provisions. The case vignettes are based upon real cases, albeit not presented precisely as they occurred. Participants will consider specifically how expert medical evidence may play out under ‗new diminished responsibility‘, in contrast to the old provisions. Participants in the workshop will be encouraged to describe their own experience and views as may be relevant to operation of the new law. Diminished Responsibility provision: Section 2(1) of the Homicide Act 1957 provided: "Where a person kills or is a party to the killing of another, he shall not be convicted of murder if he was suffering from such abnormality of mind (whether arising from a condition of arrested or retarded development of mind or any inherent causes or induced by disease or injury) as substantially impaired his mental responsibility for his acts and omissions in doing or being a party to the killing." The Coroners and Justice Act 2009 (England and Wales) provides: ―(1) A person (―D‖) who kills or is a party to the killing of another is not to be convicted of murder if D was suffering from an abnormality of mental functioning which, (a) arose from a recognised medical condition, (b) substantially impaired D‘s ability to do one or more of the things mentioned in subsection (1A), and (c) provides an explanation for D‘s acts and omissions in doing or being a party to the killing. (1A) Those things are— (a) to understand the nature of D‘s conduct; (b) to form a rational judgment; (c) to exercise self-control. (1B) For the purposes of subsection (1) (c), an abnormality of mental functioning provides an explanation for D‘s conduct if it causes, or is a significant contributory factor in causing, D to carry out that conduct.‖ Educational goals of the workshop 1. To provide participants with knowledge and understanding of the ‗new diminished responsibility‘ provisions. 2. To elucidate any uncertainties in how the new provisions may be interpreted by the Court of Appeal and the implications for the giving of expert medical evidence of alternative interpretations. 3. To provide participants with a basis for determining their own technical and ethical approach to the provision of expert evidence under the new provisions, however interpreted by the Court of Appeal. 4. Appeal. Workshop 6 Trauma - recognition, management and treatment in custodial settings Vittoria Ardino, Frances MacLennan, Piyal Sen, Andrew Forrester This workshop is organised jointly by London Metropolitan University, St. Andrew‘s Hospital, South London and Maudsley NHS Foundation Trust, HM Prison Brixton and the Institute of Psychiatry. The workshop will be run by: Vittoria Ardino - Senior Lecturer in Forensic Psychology, London Metropolitan University and Board Member of the European Society of Traumatic Stress Studies Frances MacLennan - Clinical Psychologist, South London and Maudsley NHS Foundation Trust at HM Prison Brixton Piyal Sen – Consultant Forensic Psychiatrist and Associate Medical director for CPD, St. Andrew’s Healthcare, and Visiting Research Fellow, Institute of Psychiatry Andrew Forrester - Consultant in Forensic Psychiatry, South London and Maudsley NHS Foundation Trust at HM Prison Brixton, and Honorary Senior Lecturer, Institute of Psychiatry The workshop will cover the prevalence, recognition and management of mental illness that is underlain by trauma in custodial settings. This will include psychological and criminological issues underlying the definition of post-traumatic stress disorder (PTSD), its measurement and treatment in forensic settings, and an update on current research in the area. Specific instruments for trauma assessment will be introduced and case material will be used to illustrate the practical applications of research. This will include data from the research that the authors are currently pursuing this area in HMP Brixton. The implications for service delivery in custodial settings, which may, because of their very nature, re-ignite or inflame earlier traumatic experiences, will be discussed and set alongside the development of prisonbased mental health in-reach services and the Improving Access to Psychological Therapies (IAPT) initiative (through which talking therapies have been rolled out nationally, including within custodial settings). The role of treatments in particularly vulnerable groups such as refugees and asylum-seekers, as well as prisoners who are foreign nationals, will also be discussed. At the end of the workshop, the participants will be updated on how to recognise trauma symptoms within custodial settings, including for specific groups like foreign nationals, and how to treat such symptoms within such settings. Vittoria Ardino Vittoria Ardino is a senior lecturer in Forensic Psychology at London Metropolitan University, UK, where she lectures in the MSc in Forensic Psychology. She is the President of the Italian Society for the Study of Traumatic Stress (SISST) and serves on the board of the European Society for Traumatic Stress Studies (ESTSS). She is associated editor of the European Journal of Psychotraumatology and her research interests and publications bridge clinical and forensic psychology with a focus upon the role of trauma in young and adult offenders with post-traumatic symptoms. She also offers consultancy and workshops on trauma in forensic settings. Frances MacLennan Frances MacLennan is a Clinical Psychologist with South London and Maudsley NHS Foundation Trust, working currently at HM Prison Brixton. She has a particular interest in the Improving Access to Psychological Therapy (IAPT) project and in the application of the trauma model to custodial settings. Piyal Sen Piyal Sen is a Consultant Forensic Psychiatrist with a special interest in the treatment of refugees and foreign nationals. He is involved with a number of research projects within Brixton Prison on this area, focused on the care pathway for foreign national prisoners and how trauma and criminality interact within such a group. He also has a clinical and research interest in personality disorder and the role of trauma in its development. He is the lead for personality disorder within St. Andrew‘s Healthcare and acts as a reviewer for various journals like Medicine, Science and Law, Acta Neuropsychiatrica and Foundation years Journal. He is also a member of the CPD Executive of the Royal College of Psychiatrists. Andrew Forrester Andrew Forrester is a Consultant and Honorary Senior Lecturer in Forensic Psychiatry, and Clinical Lead for Offender Mental Health, with South London and Maudsley NHS Foundation Trust and the Institute of Psychiatry, London. He has worked clinically in forensic mental health and prison services since 1998 and has led the mental health in-reach team at HM Prison Brixton since 2005. He has worked clinically in Edinburgh, London and Melbourne, and currently leads a clinical programme that focuses on severe and enduring mental illness, and a research programme that focuses on offender mental health. Workshop 7 Forensic services and commissioning in the economic downturn Dr Paul Gilluley, Dr Jeremy Kenney-Herbert, Dr Quazi Haque, Dr Mehdi Veisi, Mike Gatsi Moving Forward in Improving Quality : Economic Downturn and Forensic Mental Health Services The National Health Service is about to undergo the biggest reform in its history. The Coalition Government‘s Health White Paper, ‗Equity and excellence: Liberating the NHS‘ has set out the plan for this reform. This workshop aims to keep clinicians up to date on how these reforms will have an impact on forensic mental health services. We will explore Commissioning for Quality and Innovation and how targets have been set nationally for forensic mental health services. We will explore how the Quality, Innovation, Productivity and Prevention programme is having an effect on forensic mental health services. This workshop will discuss the work completed by a multidisciplinary working party on addressing the economic downturn and the effect on forensic mental health services. This working party was formed from a workshop hosted by the Quality Network for Forensic Mental health Services in August 2010. Objectives 1. To describes the effects of the economic downturn on forensic mental health services. 2. CQUINs and Quality standards. 3. Medium Secure QuIPP 4. To explore the interface between prison and secure services 5. To explore the interface between secure services and the community. Workshop 8 ASSESSMENT OF INTERNET OFFENDERS Sodi Mann Learning Objectives: To better understand: 1. 2. 3. 4. legal Issues associated with internet offending types and profiles of internet offenders risk assessment approaches to treatment There has been more than a 5 fold increase in convictions for indecent images of children (in E&W). Internet offenders (IO) account for a third of total sexual convictions. English Case law (Bowden 2000 & Jayson 2003) has led to a low threshold for conviction of ‗making‘ an indecent image. The courts have adapted the COPINE scale to classify images. Sullivan & Beech describe 3 motivational typologies. Research suggests IO‘s fall in 2 main clusters (using the Ward & Siegert Model): Intimacy Deficits & Emotional Dysregulation. Comparisons between IO & contact offenders reveal significant psychometric findings in terms of psychological profile. The risk profile of these 2 groups is also significantly different, with the IO group engaging better in treatment and engaging in fewer risk behaviours. The internet treatment programme (iSOTP) has a different emphasis on modules used by the core Programme. Psychometrics demonstrate an improvement in scores with iSOTP but no reconviction studies yet published. Final part of the presentation covers practical advice when assessing internet offenders. Particular focus paid to complex issue of confidentiality, where the behaviour usually involves indirect victims & any breach of confidentiality could jeopardise therapeutic engagement. A newly developed Confidentiality Guidance Document will be made available to attendees to help any future decision making process (alongside, a new Confidentiality Patient Contract) Impact of Mandatory Polygraph Testing on Sex Offender Management (and its implications for forensic psychiatry Don Grubin Learning objectives: To better understand: 1. 2. 3. 4. how polygraphy works outcomes of polygraph testing in respect of supervision and treatment whether mandatory testing disrupts therapeutic relationships how the lessons of sex offender testing can be applied to the treatment of forensic patients generally Following a three year trial of sex offender polygraph testing in the probation service in which participation was voluntary, legislation was passed to allow a trial of mandatory testing. This commenced in April 2009 in 2 probation regions in England. Although data are still being collected, much has been learned about the similarities and differences between voluntary and mandatory testing. The presentation will review the background to sex offender polygraph testing, including a discussion on how polygraphy works. Data from the voluntary programme will be presented and considered in the context of mandatory testing. The potential for use more generally in forensic psychiatry – to complement court assessments, to improve risk assessment, to enhance treatment, and to improve supervision – will be examined. The relevance of polygraph testing to internet offending will also be presented. Workshop 9 Avoiding Grief in Court John Kent, David Reiss, Aideen O‘Halloran, on behalf of FFEC with Ashley Irons The workshop is targeted at specialty trainees and newly appointed consultants; however all are welcome to attend. It will focus on generic transferable skills. Attendees from all jurisdictions will find it appropriate for their training as the content will not focus on any particular legal system. The aim of the workshop will be to promote excellence in courtroom practice. It will do this by providing a forum for interactive learning using the expertise of a leading mental heath lawyer to guide us through the key issues. Writing reports for a myriad of courts is integral to our work as forensic psychiatrists. These include tribunals (mental health), the various criminal courts, inquests, family courts and civil courts. For some it appears to be plain sailing but for many it can be daunting: one bad experience can lead to significant stress in respect of future appearances. The learning objectives for the workshop include giving you knowledge and skills in preparing for an impending court room appearance as an expert or professional witness, including how to reduce your anxiety and avoid nasty surprises on the day. The session will provide an opportunity to improve your competence as a witness in court; to reflect on the context of the court room and the role of the doctor within it; and work through some of the challenges you may face in this setting. The session will be informal, interactive, and audience participation will be welcome. Any examples of your own experiences in court, good or bad, will help to add richness and spontaneity to the session. Workshop 10 Service User Involvement in a Medium Secure Dangerous and Severe Personality Disorder Unit Caitriona Higgins Victoria Wasteney, Emma Chandler, Celia Taylor Summary not available by time of going to press Workshop 11 Film Club - The Lives of Others (Director Florian Henckel von Donnersmarck,2006) Cleo van Velsen Summary not available by time of going to press Workshop 12 Managing Violent Personality Disordered Women in Psychologically Containing Planned Environments – a strategy for the future Dr. Mary di Lustro – Clinical Lead and Consultant Forensic Psychiatrist, Women‘s Service, East Midlands Centre for Forensic Mental health, Nottinghamshire Healthcare NHS Trust. Dr. Jay Sarkar– Consultant Forensic Psychiatrist, Personality Disorder Service and Women‘s Service, East Midlands Centre for Forensic Mental health, Nottinghamshire Healthcare NHS Trust. DESCRIPTION OF WORKSHOP Over the coming years the strategy for managing personality disordered offenders is going to change substantially. The focus will shift from expensive individual and group treatments, for which substantial evidence and expertise now exists, to developing ‗psychologically informed planned environments‘, also called PIPES. Essentially, this strategy will ask service providers to create a safe, secure, responsive and supportive environment within which patients/inmates can undergo treatment. These environments are required not just within the prison estate and secure hospitals, but also in the community. Implicit in this strategy is the notion of developing and enhancing staff skills to create and maintain such environments by providing relational, as opposed to structural security. This requires training for the workforce, meaningful structured days for inmates and patients, and opportunities to learn effective interpersonal skills that can be translated onto life in the community. Presenters will give a brief outline of the Models of Care used within their service with sufficient detail to allow discussion and debate about whether Models of Care used within individual services take sufficient (or any) account of the need to provide such environments. Presenters will consider how such environments can be replicated in alternative settings, thereby facilitating the transition up or down the Secure Pathway. FORMAT OF WORKSHOP: The Workshop will include an interactive component. The facilitators of the Workshop will provide several case vignettes (depending on the number of delegates attending the Workshop) for the delegates to review. There will be debate about which elements of each patient‘s care would be most challenging and how this could be accommodated within the ‗PIPES‘ framework. During the interactive component delegates will be challenged by the facilitators referencing the research evidence base on the management of women with Personality Disorder within in-patient settings, and requested to consider how they might alter their own environments to function as a ‗PIPE‘. EDUCATIONAL GOALS OF THE WORKSHOP The Workshop will raise delegates‘ awareness and understanding of what ‗psychologically informed planned environments‘ may look like. Good practice will be shared with delegates derived from the effective running of such environments, with a focus upon future planning. Delegates can expect to develop a clear understanding of the function of psychologically improved environments. Delegates will develop an understanding of how current provision within some services results in ‗PIPES‘ and whether this might provide some solution to the lack of smooth transition between different levels of security using conflicting models of care. TARGET AUDIENCE: Those developing services (managers, clinical directors), managing services (senior MDT staff) and running services (middle-ranking & junior nursing and medical/psychiatric staff) Handouts follow: _________________________________ Slide 1 __ PIPES: A STRATEGY FOR THE FUTURE Mary diLustro Jay Sarkar _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 2 WHAT IS A PIPEs? • Psychologically Informed Planned Environments _________________________________ __ _________________________________ __ • • • • National PD strategy Treatments for individuals, groups one element Focus to shift to therapeutic environment Focus shifts to management in community _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 3 BACK TO THE FUTURE • Psychologically informed environment – synonym: Therapeutic millieu – Millieu: Awkward to spell and pronounce. What’s it? • • • • A group living situation (ward, drop-in, day centres) For children with emotional problems (adults with PDs) Whose lives are full of crises (offenders, PDs in community) Focussing on events that occur & processes that exist. - Treischman et al 1969 _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 4 PIPE: A SECURE BASE • “..actions of adults (carers) with children (offenders) and the adults’ (carers’) control of the environment can be coordinated to improve children’s (offenders’) lives.” (Trieschman et al 69) • Using the events & processes that exist in these environments as effective tools to effect change • Creating a secure base which offers safety in relationships, predictable consequences to actions, and oppurtunities to explore and learn _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 5 PIPEs are Teaching environments • Events – What goes on daily among users and carers offer opportunities for therapeutic education and reeducation of the users. • Processes – The rules, routines and practices within an environment, their implementation, and management _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 6 How people learn • ‘A-ha’ learning: Insight/therapeutic learning • ‘Me-too’ learning: Imitation/Identification • ‘Stick-and-carrot’ learning: Reinforcment • ‘Again-and-again’ learning: Repetitive events _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 7 Events: Emotional (re)learning • Events are a function of relational safety – Interactions between users and users and carers reveal ‘snippets’ into early home life – Relationships reveal underlying attachment schemes – every encounter offers opportunities for psychological education – Dependent upon capacity of group and carers to support _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 8 _________________________________ Processes: Socio-emotional learning • Rules of the environment (dos & donts) • Policies and practice that are largely inflexible and non-negotiable – – – – – ‘Reasonable’ rules for daily running ‘Extreme’ rules necessary for safety of all ‘Reinforcement’ system for behavioural change Privileges, access, leave, discharge Every social group/society creates and enforces its own rules – Adaptive and flexible __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 9 Processes of the space 1. Rules: Group v Individual Automatic v negotiated • • • • Group automatic rules (Boundaries) Individual automatic rules (assault seclusion) Group negotiated rules (exceptions) Individual negotiated rules (tailored treatment) _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 10 Processes of the space 2. Routines Planned sensible sequences of behaviour around regular events of the day, week, year. Routines around lunch, dinner, bedtimes Daily negotiations, Community/Business meetings Ward rounds requests, Self-report at CPAs/reviews Viewing and processing reports Routines for staff, MDT _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 11 Processes of the space 3. Programmes & Activities Therapeutic tasks presented by daily events Predictable vs Unpredictable What does a situation demand Capacity to bear frustration Balance between autonomy v submission Meaningful day events _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 12 _________________________________ __ 4. Conversations Psychotherapeutic conversations Life-space conversations One-line comments Who does it? Nurses, Allied profs, Medics, RC _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 13 Support & Guidance for Users • • • • Relationships with key individuals (shared ego) Group mood & structure (group ego) Institutional culture (external ego) Individual’s own abilities (personal ego) _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ Slide 14 Key Relationships • Most crucial aspect of millieu • Share/lend ego to users _________________________________ __ _________________________________ __ • Praise, share, support, etc _________________________________ • Fitness of attachment styles __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 15 Critical elements of relationships • Communication – good or bad • Social reinforcement – approval or disapproval _________________________________ __ _________________________________ __ _________________________________ • Modelling behaviour – good or bad __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 16 Group mood & structure Structure • • • • Tightly knit Clear leader Multi-dimensional ‘Top dog’-’Black-sheep’ _________________________________ __ _________________________________ Mood Aroused Relaxed Antagonistic Cooperative __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 17 Institutional culture • • • • Traditions Policies Practices User expectation of how organisation reacts _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 18 Instituion as ‘secure base’ • Supportive millieu environment • Avoiding repetition of bad experiences of past _________________________________ __ _________________________________ __ _________________________________ Millieu becomes the ‘secure base’ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 19 Individual Capacities • • • • • Emotional reactions Ego strength – how regressed Learning style Motivational levels Psychosocial stage of maturity – Trust v mistrust (suspicious) – Autonomy v shame, doubt (aggressive) – Initiative v guilt (passive) – Industry v inferiority (depressed) – Identity v Ego diffusion (PD) _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ Slide 20 Know your patient • Emotional reactions: Impulsive-emotional v Withdrawnstrategising • Ego strength: how regressed or child-like under stress • Learning style: Relational, Group-based procedural Reinforcement-orientate, Social learning • Motivational levels: Motivators internal or external • Psychosocial stage of maturity: Where is she at? _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ __ _________________________________ POSTER ABSTRACTS (A-Z by presenter) An audit into the prescription and use of sleeping tablets in East Sussex Forensic Psychiatry inpatients Dr Shakil Alam, Foundation Doctor Year 2 Royal Free Hospital London, Dr Nikolas Gkampranis Staff Grade Forensic Psychiatrist, East Sussex, Dr Peter Hayden-Smith Consultant Forensic Psychiatrist Hellingly Hospital East Sussex. East Sussex, Dr Richard Noon Consultant Forensic Psychiatrist East Sussex Aim: To monitor the use of sleeping tablets in the Forensic Psychiatric Services, looking specifically at length of stay, whether the sleeping tablets had been prescribed regularly or as required, whether the patient was still experiencing insomnia symptoms despite receiving a sleeping tablet and whether the medication was reviewed. Introduction: A patient complaining of insomnia may describe one or more of the following symptoms: difficulty falling asleep, frequent waking during the night, early-morning wakening, daytime sleepiness and a general loss of wellbeing through the individual's perception of a bad night's sleep. Method: The following hypnotic drugs were included in the study, as per Maudsley guidelines: Diazepam, Lormetazepam, Oxazepam, Nitrazepam, Temazepam, Zaleplon, Zopiclone, Zolpidem, Promethazine and Chloral pd. Data was collected through direct monitoring of medicine cards in the units, consultation of patient‘s case notes, discussion with Nursing team and discussion with Ward Doctor when required. 39 patients from the Forensic Psychiatric services at Hellingly Hospital were audited from July-August 2007. Results 98% (38) of the sample had been inpatients for more than 4 weeks, 2% (1) had been inpatients for less than 4 weeks. 67% (27) had been prescribed a hypnotic tablet. 31% (12) of the patients had been prescribed a sleeping tablet ‗as required‘. 28% (11) had been prescribed a sleeping tablet regularly, and the remainder 72% (28) had been prescribed a hypnotic tablet both on the regular and ‗as required‘ side. Worryingly 66% (26) of the treated group were still symptomatic with insomnia. 66% (26) of patients on hypnotic medication had their medication reviewed on a monthly basis; however 18% (7) of the sample group continued to experience insomnia symptoms and not have their medication reviewed. Conclusion The audit showed insomnia to be a common symptom amongst the Forensic Psychiatric inpatient sample used. Many had been prescribed a sleeping tablet, mostly on an ‗as required‘ basis, although the results show that many patients continued to suffer from insomnia despite medication therapy. Most of these patients were likely to be identified during monthly medication reviews, however there remained a significant number of patients who continued to have insomnia symptoms inadequately treated, receiving suboptimal medical therapy that was not reviewed. Some of the difficulties in performing the audit arose from being unable to objectively assess the quality of the sleep (versus subjective measures), whether there was a difference in the ways that ‗as required‘ medication was dispensed and being unable to account for multiple comorbidities that could also be giving rise to insomnia. However, the audit did identify some ways in which the service could be improved, such as by instituting weekly medication reviews for all inpatients, preferably before weekends, monitoring of hypnotics by pharmacists, on call doctors to prescribe hypnotics as stat doses rather than as required, sleeping tablets to be used only between certain hours during the night and only by senior members of the nursing team and a full medication review before discharge. Patients with Personality Disorders and Learning Disability- Closer to Learning Disability or Personality Disorder? Dr R. Alexander FRCPsych, Consultant Psychiatrist & V Chester, Research Assistant, St John‘s House Hospital, PiC LD Services, Diss, Norfolk IP22 1BA. Introduction: Within secure hospital services for people with learning disability, the rate of personality disorders is around 50%. This diagnosis shows a positive association with reconviction rates after discharge from such settings. There have been few studies to systematically examine how patients with personality disorders and learning disability (the PD-LD group) differ from either those with a learning disability alone (the LD group) or those with a personality disorder alone (the PD group). Such a three way comparison would help to define these groups better and aid in appropriate service provision. Aim: To examine how, among patients discharged from forensic services, those with personality disorders and learning disability (the PD-LD group) differ from those with a learning disability alone (the LD group) or those with a personality disorder alone (the PD group). Method: Data was drawn from an ongoing long-term outcome study that has information on over 1000 discharges from forensic mental health and learning disability services in the UK. The groups were compared on socio-demographic, clinical and forensic variables as well as treatment-outcomes. Results: There were 362 patients, spread over three groups- 48 in the PD-LD group, 97 in the LD group and 217 in the PD group. Preliminary results suggest statistically significant differences on age at first conviction and the number and types of previous convictions. The PD-LD group had the highest HCR-20 and PCL-SV scores and the longest duration of hospital stay. The numbers of post-discharge convictions were significantly different with the PD group having the highest number while survival without a reconviction was longest for the LD group. Conclusions: In terms of past risk variables, the PD-LD group scores highest and may thus be closer to the PD group than the LD group. Their rates of reconviction are lower than the PD group and in that respect they may be closer to the LD group. More recently, there have been government initiatives to treat people with learning and developmental disabilities in mainstream rather than specialist services. Implications of these findings on such a model of service provision are discussed. (Acknowledgement: This study is part of the ongoing treatment outcome project led by Professors Robert Snowden and Nicola Gray at Cardiff University). Making the HCR-20 Easier to Use Dr. James R Álvarez, Consultant Clinical and Forensic Psychologist; Dr. Ankur Agarwal, Consultant Forensic Psychiatrist; Dr. Amit Nigam, Consultant Forensic Psychiatrist; Dr. Antoinette Kotzé; Specialty Doctor; Westminster Community Forensic Mental Health (FoCuS) Team. Dr. Satinder Sahota, Consultant Forensic Psychiatrist; Dr. Dominic de Souza, Consultant Forensic Psychiatrist; Kensington and Chelsea Community Forensic Mental Health (FoCuS) Team. The HCR-20 is widely accepted as the gold standard violence risk assessment tool across a variety of settings. The current consensus in the literature is that the structured professional judgment approach of the HCR-20 is best among the range of risk assessment options available to help clinicians make decisions about patient care. Though well researched in inpatient and correctional settings, there is relatively little in the literature about the HCR-20‘s application, usefulness and ease of use in community settings. The Westminster and Kensington & Chelsea Community Forensic Mental Health (FoCuS) Teams were set up to provide community-based mental health services to mentally disordered offenders, to effectively assess and manage risk, to share this risk with our colleagues in generic services and to implement strategies to reduce it. Referrals are received from community mental health teams, general inpatient and secure units and the criminal justice system. Regular use of the HCR-20 form now used by local inpatient services revealed it to be useful, but time-consuming. It quickly became apparent that to achieve our team‘s aims efficiently and cost-effectively, it was necessary to make changes both to the current HCR-20 form itself and to the organisational processes and procedures necessary to ensure that risks are identified and communicated quickly in an actionable manner. Following the principle that risk assessments are only as good as the time and effort spent communicating them, with the author‘s consent, we redesigned and automated the HCR-20 form. Additionally, we re-engineered our organisational risk assessment processes and procedures to more effectively communicate and develop risk management plans without compromising their effectiveness for our team and referrers. In this poster we report on the process of modifying the form to meet our needs, our experience of using the modified form and describe the organisational and other issues encountered in using the tool. We also report how the modified version has fared in our practice compared to the original and how referrers have experienced the new process. We present the modified HCR-20 form and will encourage delegates to utilise this version and feedback to us their experience of it in an iterative process aimed at adding to the literature on community risk assessment. This will also inform the current revision of the HCR-20 now being undertaken by its original authors. The prevalence and predictors of violent victimisation amongst male inpatients in six English Regional Secure Units Dr Sophie Anhourya, Ms Alexis Cullenb, Professor Tom Fahyc, Dr Kimberlie Deand a-d Department of Forensic and Neurodevelopmental Science, Institute of Psychiatry, Kings College London, UK Introduction Individuals with severe mental illness are known to be at increased risk of violent victimisation relative to the general population. To date much of the research in this field has focused upon individuals living in community settings. The prevalence, predictors and persistence of violent victimisation over time have received comparatively little attention amongst inpatient populations, and very little at all is known about the risks for those receiving treatment in forensic services. Aims To examine the prevalence and predictors of violent victimisation in a sample of male inpatients in six English Regional Secure Units. Method This study utilised baseline data from 82 participants to establish prevalence and correlates of violent victimisation amongst a male sample receiving inpatient treatment in conditions of medium security. Baseline variables relating to victimisation, violence, substance misuse, inpatient behaviour, personality, symptom severity and demographic data were examined. Results In total 72% of the sample (n = 59) reported being subject to either verbal or physical victimisation over an average of 16 months follow-up, and 36.6% (n=30) reported physical victimisation alone. A total of 23.2% of the participants experienced episodes of victimisation in two of the follow-up periods and 13.4% in one follow-up period. Those reporting physical victimisation were significantly more likely at baseline to have experienced verbal victimisation, to have behaved aggressively towards others, to have engaged in a greater number of acts of violence, to have engaged in antisocial behaviour, to have had hospital leave withdrawn, to have misused substances, and to have high PCL-SV Factor 2 scores. Multivariate analysis showed previous victimisation to be the strongest predictor of victimisation. Conclusions This study confirms that the experience of violent victimisation as a male Regional Secure Unit inpatient in England is a common one. For many patients the experience of victimisation persists over time. The predictive factors we have identified share a relationship with violence risk in this group. Future studies should focus on long term outcomes and the design and evaluation of strategies aimed at reducing victimisation risk. Long-term Care in Medium Secure Services (London Mental Health Forensic Services) Dr Doreen Attard MD MRCPsych, Specialist Registrar in Forensic Psychiatry, South West London and St George‘s NHS Trust Forensic Services; Dr Bradley Hillier, Specialist Registrar in Forensic Psychiatry, Kent and Medway Partnership Trust; Dr Stephen Attard, Locum Consultant Forensic Psychiatrist, Kent and Medway Partnership Trust; Dr Paul Gilluley MRCPsych, Consultant Forensic Psychiatrist, West London NHS Trust Forensic Services; Dr Mari Harty MB BCH BAO MRCGP MRCPsych MSC DFP PhD, Consultant Forensic Psychiatrist and Associate Medical Director, South West London and St George‘s NHS Trust Forensic Services Aim: To identify the characteristics, needs and prognosis of long-term medium secure patients (longer than four years) Background review: Clinical experience shows that the population cared for within conditions of medium security (MSU) has changed. Patients are more challenging, have complex needs and require longer admissions. Method: South West London, West London and East London Mental Health Forensic Services participated in this study. Questionnaires were designed and sent to responsible clinicians of male patients admitted for over four years in MSUs within these trusts. Female patients and ‗long-stay‘ wards were excluded. The variables and opinions regarding appropriateness of security level, prognosis and reasons for delay in discharge were then examined. Results: The study identified 105 men detained within these MSUs for over four years. 83% were found to have a diagnosis of paranoid schizophrenia and 87% were on antipsychotic medication (30% on Clozapine). The majority of the index offences were series violence to person (23%). During admission, the majority of these patients need regular support from staff for personal and physical care, as well as to structure daytime activities (46%). 76% of the patient group were deemed to be at the appropriate secure levels. 25% were thought to require a less secure environment. The majority of the patients were believed to be suitably placed in a hostel 5 years after the study (47%), whereas 28% were considered to be suitable for low secure units with behavioural modification facilities and 16% in long term low secure services. It appeared that the main problems preventing progress was the severity of their mental health problems (67%). Conclusions: More patients than expected have been at this service for over five years. High rates of co-morbidity and complex needs were noted. Should they be treated in more specialised units which better meet their needs? The Point Prevalence of Metabolic Syndrome amongst patients on atypical antipsychotic medications in a secure Forensic setting in rural East Sussex. Daniel Howard Baker, 4th Year Medical Student, Brighton and Sussex Medical School, Dr Roderick Ley, Consultant Forensic Psychiatrist, Sussex Partnership Foundation NHS Trust. Background: There is increasing concern and recognition about the poor physical health of people with mental disorder. In particular, the incidence of obesity and diabetes are rising which is reflected in the general population. While there have been huge improvements in treatment such as in the development of atypical antipsychotic medications, this has come at a cost of possible worsening physical health. The potential relationship between atypical antipsychotic medication and the Metabolic Syndrome is well established. It has been reported that patients with severe mental illnesses such as Schizophrenia live 15 years less than controls without mental illness. There are multiple definitions of Metabolic Syndrome. This in part is because there is still yet to be an internationally agreed unifying factor. (1) (2) However it is generally agreed that Metabolic Syndrome is a constellation of hyperinsulinaemia with insulin resistance and subsequent glucose intolerance, hypertension and dyslipidaemia with hypercholesterolaemia and hypertriglyceridaemia. (3) Aims: As such, our primary aim was to detect the point prevalence of Metabolic Syndrome amongst a group of psychiatric patients detained in low and medium secure units who are currently taking atypical antipsychotics versus typical antipsychotics. Our secondary aim was to identify the level of monitoring of patients on established and newly introduced atypical antipsychotic regimes. We sought to highlight and make recommendations to Sussex Partnership Trust as to the current levels of monitoring undertaken towards meeting the National Institute of Clinical Excellence (NICE) guidelines. Methods: Patients were informed as to the potential of second generation antipsychotics to cause Metabolic Syndrome and verbal consent was gained. Patients were systematically screened and underwent venepuncture for full blood count, urea and creatinine, liver function tests, lipid profile including cholesterol and glycosylated haemoglobin (HbA1c) followed by height, weight and waist circumference measurements. Blood pressure was obtained by calculating the mean from three readings for reasons of accuracy. Results: Data collection will conclude imminently. Once all data subsets are available systematic analysis will occur. Results will be interpreted and patient‘s positive for Metabolic Syndrome identified. We have used the World Health Organisation (WHO) 1999 diagnostic criteria as opposed to the European Group for the study of Insulin Resistance (EGIR) or the National Cholesterol Education Programme-Third Adult Treatment Panel (NECP-ATP III). (1) This was sufficiently more flexible in accommodating the definition of obesity, allowing both waist circumference or body mass index. If a diagnosis of Metabolic Syndrome is made patients will be counselled as to the potential consequences of this diagnosis and offered medical management in accordance with NICE guidelines. The “Forensicisation” of Challenging Behaviour: The perils of people with Learning Disability and severe challenging behaviours becoming entrapped within Secure Forensic Services Dr Fergus Douds, Consultant Learning Disability Psychiatrist & Joint Associate Medical Director, The State Hospital, Carstairs, Scotland Dr Ashwin Bantwal, Specialty Registrar in Psychiatry of Learning Disability, South East Scotland Higher Training Scheme, The State Hospital, Carstairs, Scotland AIM: To report concern about the referral of individuals with more significant levels of Learning Disability (at least moderate) and very severe challenging behaviours to the high secure forensic service offered by The State Hospital, Carstairs, Scotland. This is a patient group who historically were not regarded as ―mentally disordered offenders‖ or ―forensic‖ cases. METHOD: Referrals of individuals with more significant levels of Learning Disability presenting with ―severe challenging behaviours‖ to the State Hospital‘s Forensic Learning Disability Service between August 2005 - July 2010 were reviewed. A total of 5 such referrals were identified. Common determinants were identified by reviewing each referral. These determinants were then thematically analysed. RESULTS: In terms of demographic details, all of the 5 individuals were male. The 5 individuals had no previous criminal convictions or previous contact with the criminal justice system (other than police involvement for aggressive outbursts). The identified determinants were broadly classifiable into psychiatric, environmental and staffing themes. The common psychiatric determinants were: all 5 individuals suffered from Autistic Spectrum Disorder and functioned within the moderate LD range. 3 of the individuals were felt to suffer from a co-morbid mental illness. The common environmental determinants influencing the referral to the State Hospital included: robustness and design of the referring ward; amount of available internal and external space; noise levels; heterogeneous patient groups and lack of availability of suitable off ward/day services. The common staffing determinants included: ―robustness‖ of the local team; staff numbers-both on the ward and on the campus; staff training issues; competing service demands; low morale and high frustration/stress levels. 4 of the individuals were deemed unsuitable for admission to The State Hospital. One individual was admitted due to the need for a very robust crisis placement to manage acute risk, with the caveat that a more appropriate placement had to be identified with a degree of urgency. All of the individuals are now being managed within specialist autism services, 4 in England and 1 in Scotland. CONCLUSIONS: It is a concern that following the hospital closure programme in Scotland, there is a dearth of very robust services for individuals with severe challenging behaviours and Autism, leading to some individuals being referred, inappropriately in the view of the authors, to forensic services. Expensive out of area placements detract from the ability of local/regional Health Boards to develop specialist services. Key UK Government policies in relation to commissioning of services locally for such individuals will be discussed. Why we read with our Patients Dr Celia Bell, Staff Grade Psychiatrist; Dr Kathryn Naylor, Associate Specialist in Forensic Psychiatry Dr David Fearnley, Medical Director Ashworth Hospital, Mersey Care NHS Trust Submission date 4/10/10 Mersey Care NHS Trust in partnership with ‗The Reader‘ organisation has been promoting Reading Groups within a wide range of mental health facilities since 2007. ‗Get into reading‘ is a simple invention: group members meet weekly for an hour and two things happen, a facilitator or group member reads aloud, the reading is broken up by discussion and response to the text Reading aloud can give immediate access to complex writing that might otherwise be at the least daunting and at worst unavailable to a large section of the population Reading Groups have been running within the Mental Health and Personality Disorder Units Ashworth High Secure Hospital since 2008. The facilitators are multidisciplinary; doctors, nurses, occupational therapists, senior management, librarians and psychologists. Two groups have received national recognition as runners up in the prestigious Orange Penguin Reading Group Award 2009. The reading groups have been nominated for a Mersey Care ‗positive achievement award‘ in 2010. The groups are seen as part of the Trust‘s strategy to promote well-being through culture and creativity. The groups have read an enormous variety of novels, poem and short stories and the enthusiasm is infectious. A literary festival held in October 2009 at the hospital was hugely successful, combining reading, poetry and music. The highlight was an event lead by Brian Keenan reading from his latest book. A further event will be held in October 2010. In our experience Reading Groups offer patients, increased confidence, improved communication skills, enhanced memory, enjoyment and stimulation in what may be an austere, isolating long stay environment. It is postulated that reading stimulates the brain‘s language areas, emotional centres, motor areas, and thoughts and may prevent the onset of dementia. As clinicians we see benefits for individual patients this view was supported by the SURE assessment (Service User research and evaluation) in 2008 which recommended expansion of the programme. Ashworth Hospital is the centre for the practical component of a PhD exploring Bibliotherapy which may provide more objective evidence as to the benefits. The Reader Organisation's ethos is that literature is not an aesthetic experience but practical help for being human. As Samuel Johnson wrote: ‗The only end of writing is to enable the readers better to enjoy life or better to endure it‘ As we move to towards ‗Recovery‘ models of care it is important to recognise the role of holistic approaches that take minimal resources but may have a big impact on improving patient experience of forensic care. Fitness to Plead in England and Wales: Is the Law Fit for Purpose? Dr Penelope Brown, MRCPsych LLM Preparatory Clinician Scientist Fellow and Honorary ST4 Forensic Psychiatry, Institute of Psychiatry, Kings College London The right to a fair trial is a fundamental human right, however mentally disordered defendants are often incapable of participating effectively in trials which could result in an unjust verdict. The test for determining fitness to plead has developed since the nineteenth century however it is viewed as outdated, especially as it does not embrace the principles of the Mental Capacity Act. The Law Commission have recently reviewed the legislation. Aims The aim of this study is to assess whether the legislation relating to fitness to plead is fit for purpose in the twenty-first century and to evaluate the potential impact of the changes proposed by the Law Commission on practice. Methods The history and development of the concept of fitness to plead will be summarised, and limitations in the legislation will be identified using case law examples. The equivalent laws in the USA and Jersey will be outlined in order to examine how decisional competence is considered when assessing fitness to plead in other jurisdictions. The role of the principles of the Mental Capacity Act in determining fitness to plead and the recommendations of the Law Commission will be discussed. Results The concept of fitness to plead developed from seventeenth century principles, and the law relating to how this is determined arose from the case of Pritchard who did not suffer mental illness per se. The criteria for determining fitness to plead include the abilities - to to to to to understand the nature of the understand the meaning and instruct a solicitor understand the details of the follow the proceedings of the charge consequences of entering a plea evidence trial so as to make a proper defence Cases such as R v Robertson and R v Diamond have highlighted that significant mental illness does not necessarily lead to unfitness to plead, and the law does not sit comfortably with modern psychiatric understanding. In the USA and Jersey, decisional competence is important in determining fitness to plead and reduces the threshold for findings of unfitness. It has been proposed that this should be incorporated into English law to better serve defendants‘ human rights. Discussion Incorporating the principles of the Mental Capacity Act into the test for fitness to plead could lead to significant changes in practice, such as increasing the number of defendants needing diversion into the healthcare system which would impact significantly on resources. LEARNING MORE FROM LESS AT BROADMOOR HOSPITAL: AN AUDIT CYCLE OF INFORMATION DISSEMINATION Dr Kaysi Thinn 1, Dr Pallavi Bujarbaruah 2, Dr Amalsha Vithanaarachchi 3, Dr Girija Kottalgi 4, Dr Mrigendra Das 5 1 Specialist Registrar in Forensic Psychiatry 2, 3 Core Trainee in Psychiatry 4 Specialist Registrar in Forensic Psychiatry 5 Clinical Lead & Consultant in Forensic Psychiatry Background: Winston Churchill once said about reports arising out of inquiries, ―This report, by its very length, defends itself against the risk of being read.‖ We seem to be good at reporting and investigating incidents. However, part of the cycle that seems to get the least attention is disseminating the lessons learned so mistakes do not recur. In Broadmoor Hospital we have been examining how better to ensure that recommendations and learning points from inquiries into serious incidents are passed down to frontline staff which is important for change in clinical practice. Thus, we audited how one could learn from incidents within Broadmoor Hospital, and improve dissemination of post-incident recommendations to frontline staff. Aims: The aims were that staff were to be familiar with the incident policy, be aware of serious incidents in clinical areas, their corresponding inquiries, recommendations and changes to clinical practice. Methods: Four wards were identified in which serious incidents had recently occurred (hostage-taking, a rooftop suicide, attempted suicide serious self-harm). A questionnaire was compiled to assess awareness of the policy, knowledge of the incident and incident review. Forty staff were randomly interviewed in July and December 2009 to identify changes over time. Findings & Action Plan: The first audit revealed that most staff were aware of an incident policy. Half were aware of the categories and review levels. Half were aware of the incident that had occurred but under a quarter had good knowledge of it and had seen the incident report. Three-quarters were unaware of the recommendations arising from the incident review and over half were unsure of whether practice had changed. In order to improve awareness, we produced an A4 page summary of each of the four incidents which identified key learning points with the headings: What happened? What did the investigation find? What can we learn from the incident? These summaries were displayed in the wards and re-audited. The findings were positive with dramatic improvement in staff knowledge. All were aware of the policy. Most were aware of the incident categories and review levels. Almost all knew and were reasonably knowledgeable of the incidents. Three-quarters had seen the incident review, were aware of the recommendations and what practices had changed. Most preferred only a simplified version of the incident review. Conclusions: We concluded that the best way to get the most vital information to the staff on the ground was to keep things simple and easily accessible. As a result, all of our incident review reports now have an A4 size summary poster which is well advertised across Broadmoor Hospital. Oxleas NHS Foundation Trust court liaison and diversion: a service evaluation Author Dr Amit Chatterjee Specialty Registrar in Forensic Psychiatry, The Bracton Centre Co-authors Dr Andrew Iles Specialty Registrar in Forensic Psychiatry, HMP Brixton Mrs Suzanne Ahlers Forensic Community Psychiatric Nurse, The Bracton Centre Mr Shaun Gallagher Forensic Community Psychiatric Nurse, The Bracton Centre Dr Ian Cumming Consultant Forensic Psychiatrist, HMP Belmarsh Dr Andrew Forrester Consultant Forensic Psychiatrist, HMP Brixton Dr Janet Parrott Consultant Forensic Psychiatrist, The Bracton Centre Aims The Bradley Report identified approximately 100 court liaison and diversion schemes in the UK. The idea for these schemes was supported by the Home Office in 1990 and further endorsed by the Reed Report in 1992. In his report, Lord Bradley highlighted the inconsistency between these schemes. Oxleas NHS Foundation Trust has provided a court liaison and diversion service to a range of magistrates‘ courts since 1992. We recognised a need to define our schemes and the population which they serve to identify the needs in light of the Bradley Report. We chose Greenwich Magistrates‘ Court as the pilot scheme. By evaluating our service we aim to improve our care of mentally disordered offenders. Methods Greenwich Magistrates‘ Court liaison and diversion scheme is staffed by a multi-disciplinary team of nursing and medical staff. Social work input is provided by the duty AMHP service. We collected data prospectively across a two year period (2008-2009). All data were collected anonymously. We captured the following information: volume of referrals; source of referral; defendant demographics; diagnosis; nature of offence; and assessment outcome, e.g. diversion to inpatient services, referral to community services, remand with view to further assessment. The data were analysed using descriptive methodology. Results Analysis of the data revealed a total of 247 referrals for the two-year period (2008 and 2009). 79% of all defendants referred to the service were male. The mean age of those seen was 34.1 years (range =18,68-years). 45% of defendants gave their ethnic background as white British, whilst 19% stated their ethnicity as black African and 16% as black Caribbean. Common assault was the most observed offence (22%), followed by theft/handling/receiving (11%). The remaining offences (affray/violent disorder, criminal damage, possession of an offensive weapon and burglary) each formed less than 10% of the total caseload. In those whom a diagnosis was made or known, schizophrenia was the most common (36%) followed by mood disorder (18%). Personality disorder was the primary concern in less than 10% of cases and substance misuse in 11%. In terms of assessment outcome, 13% of cases seen were diverted to inpatient services and 31% resulted in a referral to local community services. Conclusions In today‘s financial climate, budgetary cuts across the criminal justice and health sectors are inevitable and it is likely that commissioners will seek out services with tangible outcomes. Our data demonstrate the value of court diversion and liaison services in improving access to psychiatric services, in keeping with the vision set out by Lord Bradley. By evaluating our service and the needs of its users, we now have a real opportunity to further develop our service in line with the needs of this vulnerable and marginalised group of people. Service Evaluation of the Mental Health Awareness Groups held at Ashworth Hospital Dr Johannes Cronje who was working as an ST3 trainee in Psychiatry. Aims The purpose of the Mental Health Awareness group is to provide information regarding mental health difficulties, especially schizophrenia. This is done through exploring the patient‘s understanding of their diagnosis and sharing their experiences of having mental health difficulties. The Stress Vulnerability Model is introduced, enabling patients to recognize the signs and symptoms of potential relapse. Different strategies are discussed that will enable patients to manage their symptoms more effectively. They are also encouraged to access future support earlier. The aim of the service evaluation was to compare the values of questionnaires completed by the patient‘s pre and post group to see if there was any improvement in their knowledge about mental health difficulties, self-esteem and attitudes towards drugs. Methods Data was used from the Mental Health Awareness groups held at Ashworth Hospital, High secure hospital, gathered over a 3 year period. This included a total of 31 male patients who completed the group. The following measures were administered for each patient pre and post group. 1) General Knowledge of Illness Questionnaire (Smith and Birchwood 1987). 2) Culture Free Self Esteem Inventory (James Battle 1992). 3) Drug Attitude Inventory (DAI-3) (Hogan and Awad 1983). For the service evaluation the mean values were compared, pre and post group. Results In summary the patients improved their knowledge and understanding of schizophrenia and mental illness. a positive impact on their self-esteem and social skills. The group also had A description of factors associated with relapse and re-offending in patients discharged from medium secure units to South London, Lewisham integrated community forensic team C. Veasey-Connolly Social Worker Southwark York Clinic Guys Hospital Dr Rachel Daly Consultant Forensic Psychiatrist Bracton Centre Provision of medium secure care and community resources upon discharge are an intensive commitment of services to mentally disordered offenders yet there are few follow up studies of patients and it remains unclear whether specialist teams are more effective than generic services. Aim: To examine a cohort of patients discharged from medium secure units into the community and to identify whether a specialist team is more effective in addressing the needs of this group and preventing readmission and re-offending behaviour. Method: A cohort of 60 cases discharged into the community were followed up for a period of 2 years using data from electronic recording and hospital notes. Results: Black patients are over-represented in the sample and more likely to be admitted to medium secure units for a first offence. Fifty percent of patients did not relapse in the 2 year period. A re-offending rate of 18% of which 6.7% were violent appears positive compared to other discharge follow-up studies at two years did not have all the patients in the community. There appears to have been a successful outcome with patients who have a previous history of offending. Conclusion: Further research is needed with this vulnerable group. The use of this group of a dynamic clinical risk assessment to identify improvements in clinical care is recommended. Specialist teams have much to offer in engagement skills, intense case management and realistic risk assessment A COMPARATIVE STUDY OF HEALTHCARE AND PLACEMENT NEEDS IN OLDER FORENSIC PATIENTS IN A HIGH SECURE VERSUS MEDIUM/LOW SECURE HOSPITAL SETTING Dr Kavita Das, Speciality Registrar, Yr 5 (1); Dr Kevin Murray, Consultant and Clinical Director (2); Dr Rick Driscoll, Medical Director (3); Dr S.Rao Nimmagadda, Consultant Psychiatrist (3). (1)Farnham Rd Hospital, Surrey and Borders Partnership NHS foundation Trust. (2) Broadmoor Hospital, West London Mental Health Trust. (3)Thornford Park Hospital. Background An area in health care provision which is under-researched and suffers from lack of adequate facilities in the UK are services for older patients with history of serious offending. Available research on older forensic patients in the UK has reported high psychiatric morbidity and physical health problems. Similar studies on older offenders have concluded that they have more mental and physical health needs. Earlier studies on similar populations in healthcare settings have methodological shortcomings. Recent studies however conclude that assessment of healthcare and placement needs in older forensic patients is possible, using standardised needs assessment scales. Aims, Objectives, Material and Methods This is an exploratory study with an aim to compare healthcare and placement needs of older forensic patients (over 60 years) from a High Secure Hospital and medium/low secure hospital. An additional objective was to assist in service planning for the older forensic patients. Fifteen patients each, from the High and Medium/low Secure Setting were examined using the Camberwell Assessment of Needs (Forensic and Elderly version). Placement options were also compared. Socio-demographic and clinical data was collected from the medical notes. Results and Conclusions This study supports the hypotheses that there are significant differences in healthcare and placement needs of the older forensic patients in High Secure Hospital when compared to Medium/low Secure Hospital. More than half of older patients in High Secure setting were transferred from prison compared to majority of the patients in Medium/low Security Hospital were admitted from High Secure Hospital setting. Whilst, the older population was relatively younger in High Secure, compared to the Medium/Low Secure Hospital they had more unmet needs in the areas of complex physical health problems, and also reported more psychotic symptoms and treatment as unmet needs than the younger group. The older group in Medium/Low Secure Hospital had more met needs than the older group in High Secure Hospital. The two groups were significantly different in placement needs in that half of the older forensic patients in High Secure Hospital were deemed not requiring continued high secure placements and actually needed other placements. The Older group in the Medium/Low Secure Hospital, almost all needed low secure placement. In keeping with the significant findings, it is important to train staff who look after older people in identifying and monitoring needs using standardised measures and the study highlights the requirement for age specific services. An evaluation of the effectiveness of Enhanced Thinking Skills in improving the functioning of offenders with antisocial personality disorder traits Dr. Tarun Khanna; University of Manchester Dr. Michael Doyle; University of Manchester Dr. Adrian Hayes; University of Manchester Dr. Charlotte Lennox; University of Manchester Lamiece Hassan; University of Manchester Professor Jenny Shaw; University of Manchester Background: Historically there has been significant therapeutic nihilism about effective interventions for patients with antisocial personality disorder (ASPD) traits. Although, there is emerging evidence that cognitive skills interventions are effective in reducing recidivism in these patients, there is a scarcity of research studies supporting the use of cognitive skills programmes to improve functioning. Aim: To look at the effectiveness of Enhanced Thinking Skills (ETS) in improving antisocial attitudes, anger regulation and social problem solving skills in offenders with ASPD traits. Method: The methodology is a non-randomised controlled trial comparing ETS (intervention; 70 participants) vs. treatment as usual (TAU; 56 participants) in offenders with ASPD traits. Outcome measures were the Antisocial Personality Questionnaire, the Novaco Anger Scale and the Social Problem Solving Inventory-Short Form. Results: There were no significant differences between scores on baseline measures, demographic and criminal characteristics in both groups. However there was a significant effect of allocation in the ETS group on all of the outcome measures, when compared to TAU, indicating that ETS is likely to be of benefit. Conclusions: This study shows that cognitive skills programmes based on ETS are likely to be effective in improving functioning in offenders with traits of ASPD. However due to a number of limitations further research is required. A simple screening tool for violence risk in schizophrenia Jay P. Singh, Prof Martin Grann, Prof Paul Lichtenstein, Prof Niklas Långström, and Dr Seena Fazel Aims: We aimed to develop a simple tool for screening violence risk in individuals diagnosed with schizophrenia. Method: Information on 13,806 individuals with two or more hospital discharge diagnoses of schizophrenia between 1973 and 2004 was extracted from several high-quality Swedish registers. Logistic regression analyses were used to design a parsimonious screening device, the predictive validity of which was measured using four outcome statistics. The instrument was calibrated on 6,903 participants and cross-validated using three independent replication samples of 2,301 participants each. Results: Multivariate regression analyses resulted in a screening tool composed of five items. The instrument had a high negative predictive value at 94%, meaning that of those patients who were deemed low risk, 94% were not subsequently convicted of a violent offense after 32 years. The tool had a low positive predictive value, suggesting that it could not be used to identify those patients who would go on to be convicted of a violent crime. There was no evidence for additive validity when the items were weighted or three potential additional risk factors for violence were included: low level of education, parental violent conviction, and parental alcohol abuse. Conclusions: Focusing on screening out patients not at risk of violence may offer a more promising approach to risk assessment in schizophrenia than the current practice that aims to identify high risk patients. Examining the evidence for an authorship effect in forensic risk assessment: A subgroup analysis and metaregression analysis Dr Seena Fazel, Jay P. Singh, Prof Martin Grann Aims: We undertook a systematic review and meta-analysis of nine commonly used risk assessment instruments to investigate whether there is evidence for an authorship effect in the forensic risk assessment literature Methods: We collected data from 75 studies based on 29,095 participants in 97 separate samples. For 61 of the samples, new tabular data was provided directly by authors. We used four outcome statistics to assess rates of predictive validity, and analysed sources of heterogeneity using subgroup analysis and metaregression. We examined whether the predictive validity of a study was higher or lower if an author of that tool was also an author on a validation study. In addition, we explored whether there was an effect when translators of tools were authors of validation studies. Finally, we investigated whether there was disclosure of financial or non-financial benefits in investigations where a study author was also a tool author. Results: There was some evidence for an authorship effect, and the paper will present the whether this was more marked in tools employing structured clinical judgement or actuarial tools. We tested whether the authorship effect was mitigated by markers of study fidelity, such as specific outcomes or the demographics of the study sample. Conclusions: Several explanations for the authorship effect are given, its implications for risk assessment research findings discussed, and methods for minimizing its effects are presented. Clozapine therapy: Identifying patients at high-risk of developing diabetes mellitus and cardiovascular disease in low secure and community forensic setting Authors: Dr Pujit Gandhi MBBS, MRCPsych Dr Carlo Thomas MBBS, MRCPsych Dr Pradeep Pasupuleti MBBS, MRCPsych Dr Tom White BA, BSc (Hons), MB ChB, FRCPsych, Dip FM, MSc Objectives: 1. To survey prevalence of cardiovascular risk factors and pro-diabetic states in patients on Clozapine therapy in all psychiatric patients being cared for in forensic psychiatry setting in NHS Tayside 2. To determine how the services in NHS Tayside compared to a similar study in NHS Glasgow and Clyde Method: 1. All patients receiving clozapine therapy whilst inpatients or being followed up by forensic psychiatrists were identified. 2. Age, sex, systolic blood pressure, smoking status, cholesterol, clozapine dose and frequency of clozapine related blood monitoring was obtained from patients‘ case notes 3. Glucose, cholesterol and frequency of clozapine related blood monitoring was obtained using Central Vision (online resource). 4. Cardiovascular risk was calculated using the British National Formulary cardiovascular risk prediction charts. 5. Data to be analysed using simple statistics and t-test. Results: This study is a work in progress, which we intend to finish by the end of October 2010. Data is being collected from 30 patients (n=30) on Clozapine out of a total 67 patients presently being cared for in low secure and community forensic psychiatry setting in NHS Tayside. Clinical implications The risk of diabetes mellitus and cardiovascular disease is significantly increased in patients receiving antipsychotic medication, especially clozapine therapy. The risk is further increased in forensic population whose average duration of stay in the inpatient setting is much longer than general adult cohort. Identifying the patients at risk of developing diabetes mellitus and cardiovascular disease while they are in a pro-diabetic states and high cardiovascular disease risk states. Narcissitic Personality Disorder: To Treat or Not to Treat? Dr Dineka Gray (CT2), Dr Noir Thomas Consultant Forensic Psychiatrist. Ashworth Hospital, Mersey Care NHS Trust, Liverpool, L31 1HW. Aims Department of Health Guidelines (2003) outlined the need for offenders with a diagnosis of personality disorder to receive ‗appropriate‘ care from forensic services and interventions designed to provide ‗treatment‘ as well as addressing offending behaviour.1 Currently, in Ashworth Hospital, 11% of patients with personality disorder have a primary diagnosis of narcissistic personality disorder. The average length of stay for these patients is 22.1 years (compared with a mean length of stay of 6.4 years for all patients with personality disorder). It costs approximately £250,000 per patient, per year within a high secure setting, which corresponds to an average £5.5 million to ‗treat‘ an individual with narcissistic personality disorder. Our aim was to consider whether this is clinically and cost effective by looking at the number of patients with narcissistic personality disorder, their interventions and outcomes. This was particularly driven by the recent review and proposed developments in service provisions for offenders with a diagnosis of personality disorder2. Method We conducted a file review to examine characteristics of patients with narcissistic personality disorder. Data was gathered relating to demographics, PCL-R scores, length of stay, ‗treatment(s)‘, and other information pertaining to risk. Results The number of patients with a predominant personality disorder diagnosis at Ashworth Hospital is (n=72). Of these, 8 (11%) have a diagnosis of narcissistic personality disorder. Their mean age is 52.2 years (range =34-73 years), and mean length of stay; 22.1 years (median =26 years, range =2-40 years). All 8 are classified White British, and fulfil criteria for Hare Psychopathy, as assessed by PCL-R. None are prescribed psychotropic medication. 5 are detained under section 37/41 of the Mental Health Act 1983, 2 under section 37 (N) and 1 under section 47/49. In reviewing treatment, 62.5% (n=5) had engaged in therapy focussing upon core personality pathology, (psychodynamic or cognitive analytical therapy). 25% (n=2) refused all psychological intervention. 75% (n=6) had completed programmes specifically focussing upon offending and risk. Conclusions Our results indicate that these patients, often considered ‘impossible’ patients, do engage in therapy. This seems to have little bearing upon discharge, given the mean length of stay. In the absence of any clear evidence base around treatment, it becomes difficult to argue that this equates to ‗appropriate medical treatment‘. Our review suggests that detention within this small group is likely to be protracted, with difficulties around engagement, a lack of evidence base and clear outcome measures. This has massive financial, moral and ethical implications and indicates further review. Ethnic variation in juvenile delinquency Dr Muhammad Gul –ST5 [SpR] Adolescent Forensic Service, Wells Unit West London Mental Health NHS Trust & Honorary Clinical Research Fellow Imperial College London. Ms Nicole Hickey –Imperial College London Dr Matthew Hodes – Consultant Child & Adolescent Psychiatrist Central North West London NHS Foundation Trust & Senior Lecturer Imperial College London. Aim: The aim of this study was to examine ethnic variation in self-reported juvenile delinquency among a general population sample of adolescents from an inner city urban population, and to explore some of the possible causes of any variation. Method: N=327 adolescents (54% male) with a mean age of 15.1years (sd1.3) were recruited from a London secondary school and divided into six ethnicity groups: White British, White Other, Middle East/Arab, Black, Bangladeshi & Pakistani, and Mixed. Self-report questionnaires addressing family cohesion, family obligation, juvenile delinquency, religious affiliation and worship, and the Strengths and Difficulties Questionnaire were completed. The juvenile delinquency scale produced a total score and was further sub-categorized into six groups of delinquency: acquisitive, criminal damage, drug use, public drunkenness, other, and conduct problems. Results: The only measure of juvenile delinquency that showed significant ethnic variation was public drunkenness with the White British group the most likely to have exhibited such behavior and the Bangladeshi & Pakistani and Middle East/Arab groups the least likely. A similar, but non-significant, trend was also observed for drug use. The White British group also displayed the greatest versatility in their delinquency i.e., they engaged in a variety of the different delinquent behaviors. Exploring the possible causes of the ethnic variation it was found that the Bangladeshi & Pakistani and Middle East/Arab groups were the most likely to come from stable two-parent families, and had the highest scores on the measure of family obligation reflecting traditional family views. There was no main ethnicity effect for the measure of family cohesion, but the Bangladeshi & Pakistani and Middle East/Arab groups were the most likely to report a religious affiliation, to regularly attend some form of worship, & to adhere to religious food observance; the White British group were the least likely. Conclusions: Significant ethnic variation in self-reported juvenile delinquency was only found for a measure of public drunkenness, although there were non-significant group differences for other forms of delinquency. Ethnic group differences in relation to family factors including parental marital stability, attitudes to traditional family life, and religiosity may help to explain the reduced level of delinquency observed in the Bangladeshi & Pakistani and Middle East/Arab groups through the mechanism of stronger ties to family and pro-social activities compared to the White British group. Theory of Mind, Schizophrenia and Violence Miss Stephanie Harris1,2, Dr Clare Oakley1,2, Dr Avi Reichenberg2, Professor Declan Murphy2, Dr Marco Picchioni1,2 1. King‘s College London, Institute of Psychiatry, St Andrew‘s Academic Centre 2. King‘s College London, Institute of Psychiatry, Department of Forensic and Neurodevelopmental Sciences Background There is a well recognised association between schizophrenia and violence. While substance misuse, especially in community settings, is important, there is relatively little known about other illness specific factors that might drive this link. One factor to consider is social functioning deficits. Method We conducted a literature database search and manual cross referencing, using combinations of the following terms: schizophrenia, psychosis, antisocial, violence, aggression, forensic, theory of mind, emotion recognition and facial affect. All identified studies were subsequently included in our review. Results It is widely accepted that theory of mind (ToM) deficits are found in individuals with schizophrenia; however few have attempted to examine this in relation to violence in the disorder. Despite a modest number of studies and methodological inconsistency, there is increasing evidence that patients with schizophrenia who are violent exhibit greater/better ToM abilities than those with schizophrenia who are not. When compared with violent individuals with personality disorder, only more complex 2nd order ToM is compromised in schizophrenia. However, violent patients with schizophrenia exhibit impaired ability to recognise facial emotions in others, in particular fear and anger, compared to their non violent counterparts. This is consistent with findings in non psychotic conduct disorder patients who also manifest marked impairments in facial recognition and non psychopathic antisocial personality disorder subjects. Conclusion This data suggest that a proportion of violent schizophrenia patients, possibly those with premorbid conduct disorder or antisocial personality traits, are likely to be characterised by a combination of good mentalising and poor empathetic inferencing abilities as well as impaired inferencing of mental states. Although many of these studies are compromised by methodological inconsistencies, there is increasing evidence that social functioning deficits such as ToM, emotion recognition and empathy may play a significant role in informing our understanding of violence and aggression in schizophrenia. Future research should concentrate on more detailed investigation of violence in schizophrenia, examining comorbid disorders in order to identify illness specific aspects of social functioning focused on schizophrenia itself. Role of a Community Forensic Learning Disability team Dr Ragini Heeramun ST4 Learning disability and Forensic Psychiatry, Severn Deanery Dr Elizabeth O‘Mahoney CT3, Severn Deanery Dr Shamim Dinani Consultant Psychiatrist in Learning Disabilities, South Bristol CLDT, Bristol Wendy Goodman Specialist Nurse, Avon Forensic community Learning Disability team, Bristol Introduction There has been a huge emphasis on expansion of wider community services for offenders with learning disability.The Avon Forensic CLDT provides specialist multidisciplinary service to individuals with learning disability who are or have been in contact with the Criminal Justice System. Aim 1. 2. To identify sources and reasons for referral and look at key interventions provided to those eligible for the service To consider inappropriate referrals and needs of those not eligible for the service Methodology All referrals from July 2009 to June 2010 were considered and the referral letter and assessment details were accessed. Results There were 68 referrals to the team during this period comprising of 65 clients. The majority of the referrals were from Community Learning Disability Teams closely followed by the CJS. More than half were referred for risk assessment and to access adapted offending programs. A fifth of the referrals were for eligibility assessment. Sexual offences consisted of 37% of the referrals, violent offences 30%, acquisitive 14% and arson 6%. Services provided by the team included eligibility, cognitive and forensic risk assessments, adapted offender intervention including individual work and groups (Good Thinking Skills and Sex Offender Treatment Program), monitoring of clients in out of area secure placements and liaison with CJS and other services. 15 referrals were not eligible for the service. This included clients with cognitive impairment secondary to other mental health or neurological problems. Half were from Probation services. The main reason for referral was to access adapted offending interventions. Needs identified during assessment included housing and tenancy support, intervention around addiction and offending behavior, mental health, vocational and literacy skills. Conclusion The Avon Forensic CLDT is a small specialist team working with adults with learning disabilities who have committed offences or are at risk of offending. They provide a range of services such as risk assessments and specialist therapeutic work. They play a key role in multiagency training and liaison with the CJS. The majority of referrals were from CLDTs and CJS. The main purpose of referrals was for risk management and offender interventions specific to those with learning disability. A key area of need identified is for adapted offender program in the community for individuals with borderline learning disability and cognitive impairment secondary to other conditions. We would recommend further development of offender management interventions for these clients via probation services or jointly by probation and learning disability services. Outcome measures used in forensic secure units for people with learning disability in England: a systematic review Authors: Dr.Avinash Hiremath1 Dr.Regi Alexander2 1. Locum Consultant, Leicestershire Partnership NHS Trust 2. Department of Psychiatry, St John‘s House Hospital, PIC LD Services, Diss, Norfolk IP22 1BA and Honorary Visiting Clinical Fellow, University of Leicester Aims: Services are increasingly expected to demonstrate the success of their care pathways in the form of outcome measures. There is, however, a lack of robust standardised outcome measures applied to patients with learning disability using secure services. This paper systematically reviews literature for various outcome measures used in Learning Disability Secure Units in England. Methods: A detailed literature search was done on relevant databses using MeSH search terms. Studies were selected on the basis of defined inclusion criteria. Data from the studies was extracted on a pre-designed form. As the variables extracted from the studies are not homogenous, data has been presented in a narrative review. Results: There are few studies describing outcome measures for people with learning disability in England. A variety of outcome measures were used including recidivism, length of stay and discharge placement. Most studies described variables related to their study population. Very few studies described care pathways and interventions, which made a valid comparison difficult. Even fewer had a control group for interventions made. Within the comparisons made, it appeared that the length of stay correlated with the level of security. As in mainstream forensic research, variables used to describe recidivism were the commonest outcome measure. Therefore, there is not enough clarity on whether the measures are adequately descriptive, standardised and reliably replicable. The merits and shortcomings of the measures used will be discussed and compared with findings from the recent HTA systematic review of outcome measures used in forensic mental health research.( Health Technology Assessment 2010; Vol. 14: No. 18) Conclusion: In a time when outcome measures may be used to determine quality and guide commissioning, it is important for services to use valid, reliable and user-friendly outcome measures. The measures must reflect the progress of patients through the care pathways and must relate to the clinical, humanitarian, rehabilitation and public safety domains. More work is needed in this area. Treatment with Triptorelin in mentally disordered sex offenders: Case series from a High Secure Hospital. Dr David K Ho 1, Dr Gillian Paterson1 , Dr Judith Harrison1, Dr Girija Kottalgi1, Dr Jose Romero-Urcelay1, Dr Mrigendra Das1 1. Broadmoor Hospital, West London Mental Health Trust, UK. Introduction The treatment of mentally disordered sex offenders includes a range of therapy from pharmacological agents to psychological modalities. Treatment is often complicated by poor compliance due to undesirable side effect profiles of pharmacological agents and patient motivation in psychological therapy. The evidence suggests that the best treatment involves a combination of both modalities. This high secure hospital provides significant expertise in managing high risk sex offenders using combined modalities which includes antilibidinal medication. Whilst historically Cyproterone Acetate was the first line treatment, more recently Triptorelin, a gonadorelin analogue in the form of long acting depot injection is being used. Method We report our clinical experience of using Triptorelin in seven patients treated at Broadmoor Hospital. All patients provided informed consent for this report. Treatment using Triptorelin was monitored through subjective and objective measures. Subjective measures included interviews with patients to obtain self reported levels of sexual arousal and sexual fantasy profile. The objective measures included the reported number of sexually related incidents, hormone levels (testosterone, leuteinizing hormone and follicle stimulating hormone), clinical impression from the treating team and participation in psychological therapy. Where available, penile plethysmography (PPG) recordings were also reported. Findings All patients reported a sustained decrease in sexual arousal, fantasy and masturbation since the commencement of Triptorelin. Side effects such as hot flushes were tolerable and patients remained compliant. DEXA bone scans were performed to monitor the development of osteoposoris, a known side effect. None of the patients experienced deterioration in bone density. In the objective measures reported, all seven patients experienced a lowering of serum testosterone. Testosterone contributes to the maintenance of sexually aggressive behaviour. There was also a decrease in the number of sexually related incidents reported. In addition, the treating teams observed a sustained improvement in treatment adherence amongst these patients, including increased participation in psychological therapy. There was also an improvement in temperament with decreased levels of aggression. It was noted that being on Triptorelin treatment made Medium Secure Units more likely to accept these patients in their care-pathway. Conclusions The use of Triptorelin in conjunction with psychological treatments should be considered for high risk mentally disordered sex offenders. This case series demonstrates its benefits including contributing towards progression to lower dependency and medium secure placements. Along with positive clinical outcomes of behavioural improvement and reduced sexually related aggressive behaviour, treatment was well tolerated and compliance was good. This is crucial in the rehabilitation of this group of patients who present a serious risk to society. Legal Automatism: The only defence “open to an honest man”, or “the last refuge of a scoundrel”? Dr Muzaffar Husain MBBS MA(Phil) MRCPsych, ST5 in Forensic Psychiatry, John Howard Centre, London, United Kingdom Dr Asim N. Suddle MBBS MRCPsych, Consultant Forensic Psychiatrist, North London Forensic Service, London, The legal defence of automatism refers to unconscious, involuntary behaviour. It remains established as a defence to criminal liability in most jurisdictions derived from English common law. In nearly all such jurisdictions, the legal framework for analysing automatism has been subsumed under the framework for allowing the insanity defence. In this article, we have defined the defence of automatism, and briefly surveyed its history in criminal law. We have analysed the most recent judicial interpretations of the defence, its limits and remit, in all English speaking jurisdictions. We have extracted the main legal guidelines for allowing the defence in English courts. We have also reviewed and summarised what the courts have come to expect from medical expert evidence in considering this defence. These legal expectations relate to the challenges inherent in medically assessing defendants who claim automatism. Furthermore, clinically, automatism may derive from a range of medical causes which might require medical treatment, not all of which can, or should, be provided in secure psychiatric treatment settings. We have enumerated what these medical causes might be. These causes require treatment which creates unavoidable conflict in the existing legal framework between the medical needs of the automatism acquittee and the need for public security. We conclude by proposing an alternative framework which might resolve this conflict by separating the treatment needs of automatism acquittees from the management of the risk they present to the public. We propose the increased involvement of the probation service for the latter task. Such an enhanced partnership between the health service and the criminal justice system might deliver a better standard of clinical care to such defendants, as well as address the legitimate needs of public safety. The Dangerous and Severe Personality Disorder Programme - an outside critique Dr Yasir Kasmi B.Sc. (Hons.) MBChB MMedSc MRCPsych, Consultant Forensic Psychiatrist, the Humber Centre The Dangerous and Severe Personality Programme (DSPD) attempted to address the previous Government‘s frustration at psychiatrists‘ unwillingness to deal with untreatable psychopaths, but also reflected tougher sentencing practices throughout the 1990s, high profile homicides, advances in risk assessment and psychological therapies and similar Dutch and Canadian programmes. The tone of successive Government papers and Mental Health Bills highlighted the public protection agenda and the erroneous perception that changing law modifies practice. Almost a decade later, the amended Mental Health Act subtly altered definitions of treatability and mental disorder, yet the DSPD programme had already started. Treatment for mental disorder ranges from cure to containment. It is justified by therapeutic necessity and needs to be convincingly shown. There is no Convention right to treatment derived from detention on the grounds of unsound mind, only that detention should take place in hospital, so the debate on altering treatability was largely irrelevant. The original subjective DSPD criteria have been largely replaced by the Psychopathy Check List, though false positives, training and reliability are significant issues. The DSPD concept has been criticised as a misuse of psychiatry to advance the public protection agenda by medicalising crime, where society‘s problems are increasingly attributed to mental disorder. Creating new clinical conditions produces the illusion of knowledge and power and quells anxiety, yet expensive new services are unlikely to be a panacea and if offending is attributed to the individual patient, we ignore wider socio-cultural causes. Sceptics were concerned that doctors would be cast as agents of social control, breaking GMC ‗best interests‘ guidelines and even the Hippocratic Oath. Early evaluation has revealed that candidates spend time in non-assessment activities, are bored and have limited contact with their clinical team and receive around an hour of therapy per week, with hospital places costing significantly more than a prison place. Other limitations include correct identification of suitable candidates, with only a third meeting the criteria in one sample 1, the numbers needed to detain in order to prevent one DSPD offence and high prevalence within sentenced prisoners 2, the limitations of extrapolating risk assessment tools to the individual, a lack of step down services, and how different philosophies exist within the prison and hospital systems. It is a costly service and if it fails, future investment is less likely. The system of indeterminate sentences for public protection is likely to become its successor. A cautionary tale indeed. References 1. Tyrer P, Cooper S, Rutter D., et al. The assessment of dangerous and severe personality disorder: lessons from a randomised controlled trial linked to qualitative analysis. The Journal of Forensic Psychiatry and Psychology 2009; 20: 132-146. 2. Ullrich S, Yang M, Coid J. Dangerous and severe personality disorder: An investigation of the construct. International Journal of Law and Psychiatry 2010;33: 84-88 Audit of Medical Clerking-In on In-Patient Admission to St Andrew‟s Healthcare, Birmingham (Independent Sector Medium and Low Secure Unit) Dr Sobia Tamim Khan Rationale All patients at time of admission to psychiatric in-patient care should have in-depth medical assessment and physical health screening. Aims -To evaluate the quality of medical assessments including history and mental state examination at time of admission. -To evaluate if physical examinations and investigations were carried out at the point of admission. Objectives To obtain and evaluate quantitative data to establish if standards are being met for the above identified aims of the audit. Standards Standards are devised from the following national guidelines. GMC Good Medical Practice Guideline (Good Clinical Care) NICE Guidelines Research Evidence CQC/CQUIN Standards All patients at time of admission to St Andrew‘s Hospital Healthcare, Birmingham should have the following completed and adequately documented in their electronic case notes. -Psychiatric History including relevant psychological and social factors -Mental State Examination -Risk Factors -Physical Examination -Investigations Method This is a retrospective audit of medical assessments at time of admission. Information is collected using a specifically designed data collection tool. The audit will collect data from first 50 admissions to the hospital since its opening in March 2009. The data sources would include admissions department and RiO electronic notes. All collected data will be evaluated and compared to standards by the auditors and results will be generated. Dissemination of results Results and recommendations from the audit will be discussed at the Multi-Disciplinary CPD Meeting. They will be passed on to the Clinical Governance Committee. Further comments and final recommendations will be electronically circulated to all department heads, ward managers and medical staff. Re-audit To re-audit in 6 months time after implementation of recommendations. Time Line Audit proposal approved- July 2010 Data collection- October 2010 Submission of initial report to audit meeting-November 2010 Development of Action Plan (following consultation) Proposed re-audit date-6 months Submission of final report (audit cycle completed) to audit meeting-2011 Publication-Following completed audit cycle Audit cycle of admissions into The State Hospital Scotland Dr Khuram Khan Higher Specialist Trainee in Forensic Psychiatry NHS Lothian Dr Duncan Alcock Associate Medical Director The State Hospital An audit was carried out in September 2010 to ascertain whether The State Hospital was complying with the current admission‘s policy. This audit was part of an audit cycle originally carried out in March 2003. The current guidelines and procedures for referral and admission to The State hospital 2005 states that ―there should be a response to all referrals within 2 weeks and patients should not wait longer than 3 months for admission‖. Aims Ascertain the timeline between referral, assessment and admission Determine where patients go on discharge from admission Ward Identify and describe a range of patient characteristics in relation to the referral and admission Method All patients admitted between June 2008 and February 2010 (sample size = 37) were included in the study An audit tool was developed Data sources included medical files held in medical records and electronic data base through the medical records manager Results 76% of patients in 2010 as opposed to 84% in 2003 were seen within two weeks of referral 40% of patients stayed for 21 weeks or over in 2010 in admission ward as opposed to 7% in 2003 Homicide (30%) was the commonest index offences on admission in 2010 as compared to assault to severe injury and breach of the peace (28% each) in 2003 Transfer for treatment direction (an order that is made by the Scottish Ministers under Section 136 of the new Act which allows the transfer of a prisoner to hospital for treatment of a mental disorder) was the commonest section (32%), patients were admitted under in 2010 The majority of patients in 2010 and 2003 were transferred from admission ward to other wards in State hospital 84% of patients were admitted within 12 weeks of assessment in 2010. An exact comparable figure was not available from the 2003 audit but 82% of patients were admitted within three weeks as compared to 57% in 2010 35% of patients were admitted from courts in 2010 and 40% in 2003 35% of patients were admitted from prisons in 2010 and 26% in 2003 41% of patients had a primary diagnosis of schizophrenia on admission in 2010 as compared to 79% in 2003 In 2010 assessment of mental state was the commonest reason (14%) for admission. Violence towards others (74%) and nature of index offence (84%) were the biggest reasons in 2003 The majority of patients in 2010 and 2003 came from Greater Glasgow health board Conclusion Results in 2010 could be explained on the basis of the following reasons: A new law, the Mental Health (Care and Treatment) (Scotland) Act 2003 came into effect Prolonged assessment process due to increased number of MDT members involved Patients with more complex needs and serious offences are now being admitted in TSH. Prevalence of co-morbid mental disorder and substance misuse in a Low Secure Forensic Service: Implications for treatment and management. Dr J P King1, Anna Williams2, Lydia Sudbury2, Kieran Lathan2 and H Y Leung2 1 Forensic Psychiatry Unit, Newsam Centre, Seacroft Hospital, Leeds 2 University of Leeds Aims: To determine the prevalence of co-morbid mental disorder and substance misuse in patients in the Leeds Low Secure service because such patients are known to have poorer outcomes including treatment resistance, higher relapse rates, suicide and recidivism. To identify the types of substances used to inform the likely treatment approaches required. Method: A substance use screening tool was developed and each patent‘s key worker was asked to complete it with the patient between October 2009 and February 2010. The tool captured information on demographics, diagnosis, index offence and substances used currently or in the past. Of the 125 patients in the service (45 inpatients and 80 out-patients) 91 were interviewed giving a response rate of 73%. All inpatients were interviewed. Results: 65% (n=59) had a diagnosis of schizophrenia. 59% (n=54) had a past or current history of daily or regular use of illicit substances and /or had a CAGE score of 2 or above. 36% had a current or past history of illicit substance misuse. Alcohol (33%), Cannabis (25%) and Stimulants (21%) were the most commonly used substances. Of the patients identifying problematic substance use, 59% (n=13) had had treatment in the past but 41% (n=9) had not. Of those patients with a recorded index offence and substance abuse, 48% thought their substance misuse was a factor in their offending. 66% of patients smoked tobacco and interestingly 25% stated they wished to stop. This study shows substance misuse is a significant problem in a low secure forensic population. In line with Department of Health guidance a strong argument can be made for integrated care (substance misuse interventions delivered by mental health staff). Needed interventions are likely to be non pharmacological as well as pharmacological. This is because the most commonly used illicit substances were Cannabis and Stimulants for which pharmacological intervention is not available or is of limited value. The high prevalence of potentially harmful or hazardous alcohol consumption merits the service developing alcohol education/reduction programmes. Patient friendly smoking cessation initiatives are required. A survey of preference regarding the terms used to describe people who are resident in a secure mental health service Miss Amanda Langé, Mr Geoff Dickens, Dr Marco Picchioni St Andrew‘s Academic Centre, Kings College London Institute of Psychiatry, Northampton, NN1 5BW Aims: Language can stigmatize or empower people. Various terms are used to refer to users of forensic psychiatric services but, to date, their preferences remain unexplored. Methods: Prospective, cross-sectional survey design with gender stratified random sampling. N=100 people resident in forensic mental health services at St Andrew‘s Healthcare, UK were interviewed about their preferences. Four terms were presented; participants selected one preferred term and ranked terms in preference order. Results: Participation rate was 45.9%. ―Patient‖ was preferred by the most respondents, but not by a majority (41%, 95% CI 33.9% – 48.1%). ―Client‖, ―Service User‖ and ―Consumer‖ were preferred by 21% (95% CI 15.1% - 26.9%), 16% (95% CI 10.7% 21.3%) and 3% (95% CI 0.5% - 5.5%) respectively. 19% (95% CI 13.3% - 24.7%) preferred another term or expressed no preference. Distribution deviated significantly from chance (Χ2 = 37.4, df=4, P<0.0001). ―Patient‖ was ranked as one of the top two preferred terms by 67% (60.2% - 73.8%) of participants, ―Service User‖ by 54% (46.8% - 61.2%), ―Client‖ by 50% (52.7% - 57.2%) and ―Consumer‖ by 12% (7.3% - 16.7%). Distribution was not random (Χ2 = 36.7.4, df=3, P<0.0001). ―Patient‖ was ranked the least preferred term by 11% (95% CI 6.5% - 15.5%) of participants, ―Service User‖ by 18% (95% CI 12.4% - 23.6%), ―Client‖ by 8% (95% CI 4.1% - 11.9%) and ―Consumer‖ by 52% (95% CI 44.8% - 59.2%). Distribution was not random (Χ2 = 55.4.4, df=3, P<0.0001). Conclusions: ‗Patient‘ was preferred by the most people, but not a majority. Most respondents ranked it their first or second choice, and it was disliked by few. Client‘ and ‗service user‘ were acceptable to most and not widely disliked. ‗Consumer‘ was unpopular. It remains unclear whether health care organisations will be able to accommodate these views in communication and literature. The effect of prison on the mental health of young offenders Dr Charlotte Lennox; University of Manchester Professor Mairead Dolan; Monash University, Melbourne Australia Professor Jenny Shaw; University of Manchester In recent years there have been improvements in the range of health services provided for young offenders while in prison. However, prisons are still considered to be harsh environments. Few research studies have looked at the effect of prison environment on prisoner‘s mental health in general or on those with pre-existing mental health problems. Studies that have, have shown that mental health symptoms in prison generally improve over time and most prisoners, even those with mental health problems, do not experience deterioration in their mental health whilst in custody. Aim: This study aimed to assess how time spent in prison impacts on the mental health of young offenders with and without mental health needs. Methods: In this observational cohort study, a consecutive sample of young offenders, taken from the list of new receptions, were approached for inclusion within three days of reception. 219 male young offenders were recruited, with a mean age of 16.56 years. Baseline assessments, including the Massachusetts Youth Screening Instrument [MAYSI-2]; The Salford Needs Assessment Schedule for Adolescents [SNASA] and Kiddie Schedule for Affective Disorders and Schizophrenia [K-SADS] were completed within two weeks of reception. Participants were then reassessed at three and six months post baseline on the same assessments to document any change in mental ill health and need. Results: MAYSI-2 baseline scores were used to assign prisoners into two groups, those with high level of mental health symptoms (High MHS) and those with low level mental health symptoms (Low MHS). Repeated measures ANOVA‘s were used to assess differences between the two groups over the three time points. During time in custody there were significant reductions in MAYSI-2 scores and level of need on the SNASA; reductions on both assessments were seen at similar rates for both groups. Clinical caseness was also assessed. Participants were tracked to see who was considered a case and not a case at each time point on the SNASA and K-SADS. Of the 200 participants identified as not a case at baseline on the K-SADS, only two developed mental illnesses severe enough to reach psychiatric diagnosis criteria while in prison. Conclusions: This study found that there was a significant decline over time of mental health symptoms and very few develop mental illnesses severe enough to reach psychiatric diagnosis criteria while in prison. Therefore it appears that in general, the prison environment did not exacerbate psychiatric symptoms. The significance of protective factors in the assessment of risk Dr Charlotte Lennox; University of Manchester Carlene King; University of Manchester Lamiece Hassan; University of Manchester Professor Mairead Dolan; Monash University, Melbourne Australia Professor Jenny Shaw; University of Manchester Background: Identifying and predicting those who are at risk of violence is a key component of clinical practice in child and adolescent psychiatry. There have been numerous prospective longitudinal birth-cohort studies identifying risk factors associated with violence. However few studies have explored protective factors in the assessment of risk, despite acknowledgement that protective factors may play an important role. Aim: To examine the significance of protective factors in assessment of risk using the Structured Assessment of Violence Risk in Youth (SAVRY). Methods: The SAVRY was completed on 135 male adolescents in custody in the UK. Data on previous offending and childhood psychopathology were collected. Participants were prospectively followed-up at 12 months using data from the Home Office Police National Computer (HOPNC). Results: Participants with protective factors were older when first arrested, were less prolific offenders, and had fewer psychopathological problems. The number of protective factors present was significantly higher for participants who did not reoffend during the follow-up. The total number of SAVRY protective factors significantly predicted desistance at follow-up and resilient personality traits was the only significant individual protective factor. Conclusion: Protective factors might buffer the effects of risk factors and a resilient personality may be crucial. Protective factors should be an essential part of risk assessment and risk management. Interventions for high-risk adolescents also need to focus on enhancing these protective factors. Mail monitoring in a high secure hospital: a very peculiar practice Dr John Milton, Consultant Forensic Psychiatrist, Rampton Hospital, Nottinghamshire Healthcare NHS Trust Introduction High secure hospitals are unusual as the hospital managers (and approved staff, sometimes known as ‗mail monitors‘ or ‗mail censors‘) have the authority to review and potentially withhold a ‗postal packet‘ if requested by a recipient or if it is deemed to potentially cause distress or harm to a patient or others. There are some exemptions to this and the overall process is monitored by the Care Quality Commission (CQC). There has not been a published clinical review of this practice in recent years. Aim I undertook a retrospective survey of mail monitoring at Rampton High Security Hospital during 2008 with the aim of determining the numbers of patients subject to formal monitoring, the patient characteristics and the number of mail items witheld and the recorded reasons. Method This survey was part of a three phase project (later to include an audit of practice against policy guidelines and then a questionnaire survey of Responsible Clinicians, RCs, for consensus on the threshold for monitoring). The survey involved identifying, from the mail censors‘ records, all patients subject to formal mail monitoring (at the request of their RC) on a census date in 2008, those patients whose mail was witheld during 2008, the number of mail items witheld during the year and the reasons recorded for this. Some broad patient characteristics (such as gender, service location) were noted. Results There were 161 items of mail witheld during the study period, 56 items of in-coming mail, 97 items of out-going mail and in 8 cases the record was unclear. In addition 30 items of internal hospital mail were withheld. Three patients were responsible for 70 of the 161 items. Twenty seven percent of patients were subject to formal mail monitoring on the census date, over half of these for monitoring outgoing mail. Almost half of the women patients were subject to mail monitoring compared to 16% of the male mental illness patients. Almost 80% of outgoing mail items were withheld because the contents were deemed distressing whereas there was a range of reasons for witholding incoming mail. There was a three-fold variation in RC practice in some directorates. Few patients who had mail witheld appealed to the CQC. Conclusion Further study will audit the quality of the mail monitoring practice involving RCs and consider the apparent variation in RC practice. Findings from Ashworth and Broadmoor Hospitals would be interesting for comparison. ADMISSION TO HIGH SECURE HOSPITAL; CARE PATHWAYS, BED VACANCIES AND DELAYS Presenting Authors: Dr Kashmeera Naidoo, CT2 trainee, Ashworth Hospital, Merseycare NHS Trust Dr Edward Silva, Consultant Forensic Psychiatrist, Ashworth Hospital, Merseycare NHS Trust Dr Birgit Völlm, Clinical Associate Professor, Institute of Long waiting times and backlogs are recognised in most NHS services but it remains unclear whether lack of capacity is the main cause of delays. Silvester et al. (2004) suggest a sophisticated analysis of organisational processes to better understand the reasons for queuing, e. g. by applying insights from Erlang‘s queuing theory (Erlang, 1909) to NHS waiting lists. In the Forensic setting, the Bradley report from DoH (2009) recommend a target of 14 days to transfer a prisoner with acute, severe mental illness to an appropriate NHS healthcare setting Aim: To determine current waiting times for admission to Ashworth Hospital for PD and MI patients and assess these against current standards To determine reasons for delays considering patient and organisational factors ( referrer, the patient and Ashworth Hospital) To develop recommendations to improve current practice and reduce waiting times This is a re-audit from 2004-05 (Völlm, Daley and Silva, 2009 ) Method Referrals from April 2009 to April 2010 to Ashworth Hospital were considered and their progress tracked. Relevant documentation was studied to obtain further information. Results During this period, 61 referrals were received, 52 were considered by the panel for admission and 36 were admitted to Ashworth Hospital There are no current national standards regarding admission times to high secure services, however, according to the national standards set out by the Best Practice Guidance (DoH 2007) for medium secure units, a decision should be made within 6 weeks. According to local Ashworth Hospital standards, a panel decision should be made within 3 weeks of referral. In our audit all cases were reviewed by panel within 3 weeks which meets national and local standards. The source of referral, distance of referral to Ashworth Hospital, diagnosis and eventual outcome did not have a significant effect on waiting times of the various stages from referral to admission. According to Kaplan Meier analysis, 80% of referrals were admitted within 70 days, this falls well within suggested national guidelines of 6 months (180 days) by 2005 (NHS plan DoH 2000). Overall, despite more stringent local standards, absolute performance has improved from 2004-2005 Conclusion It seems evident that delays in admission to Ashworth hospital are not a result of lack of capacity. Even with admission ward bed shortages, available beds through the hospital are not being fully utilised. Factors such as time taken to assess the patient should be given consideration. An Audit of Psychiatric Referrals at a Secure Children‟s Home. Mr. William Norton, 4th Year Medical Student, University of Leeds Dr. Abdullah Kraam, Consultant Child and Adolescent Psychiatrist There is significant evidence indicating a high incidence of psychiatric morbidity and mental health need for young persons (YPs) held within secure accommodation. Standards developed from the Youth Justice Board and the Department of Health detail a need for early and continual assessment of these needs, as well as access to comprehensive Child and Adolescent Mental Health Services. This audit focused on a mental health clinic held at a Secure Children‘s Home (SCH) and compared its efficacy to these standards. A retrospective audit of 24 boys who attended a mental health clinic between October 2009 and May 2010 at a SCH was designed and implemented. The audit tool was developed to analyse the assessment of a YPs mental health problems prior to arrival at the home, the referral process to the clinic and the outcome shown in this clinic. The YPs had an average age of 14 and 10 months, with 78% resident in the Yorkshire and Humber region. The admission documentation indicated 50% have had previous CAMHS involvement with high levels of self harm and alcohol and cannabis abuse. Initial assessments indicated 58% had a mental health problem recorded. At the clinic, 6 young persons had a confirmed diagnosis of ADHD and 7 were defined as having no mental illness. Other impressions included conduct disorder, mood disorder and behavioural difficulties. The audit indicated there is an inconsistence approach to the assessment of YPs and supports the introduction of comprehensive and quantifiable screening tools. There is a significant mental health need at this secure children‘s home which optimally should be met with a comprehensive specialist multi-disciplinary mental health in-reach team. The high proportion of YPs from one strategic health authority supports the development of specialised commissioning groups. Violence in schizophrenia: imaging studies Dr Clare Oakley1,2, Miss Stephanie Harris1,2, Professor Tom Fahy2, Professor Declan Murphy2, Dr Marco Picchioni1,2 1. King‘s College London, Institute of Psychiatry, St Andrew‘s Academic Centre 2. King‘s College London, Institute of Psychiatry, Department of Forensic and Neurodevelopmental Sciences Background There is firm evidence to support an independent association between schizophrenia and violence, though little indicating the illness-specific factors that drive the association. There are an increasing number of structural and functional imaging studies that attempt to identify the biological substrate for violent behaviour in schizophrenia. Method We conducted a database literature search using combinations of the terms schizophrenia, psychosis, imaging, MRI, antisocial, aggression and violence. We included all MRI studies identified, nine structural, five functional and one diffusion tensor imaging. Results There are considerable methodological inconsistencies in the definitions of violence employed across studies and the inclusion of patients with co-morbid antisocial personality disorder and substance misuse. Despite this, there is limited but consistent evidence of reduced grey matter volume in the hippocampus and medial temporal lobe in patients with schizophrenia who are violent. There is further evidence of probable grey matter volume loss and cortical thinning in the medial frontal lobe. The few functional studies show reductions in frontal activity in response to working memory and an emotional face paradigm, but increases in a response inhibition task. There is limited but consistent evidence of impaired structural and functional connectivity between frontal and medial temporal lobes. Conclusion Despite the methodological challenges, there is emerging evidence that violent patients with schizophrenia are characterized by medial temporal and probable frontal lobe deficits. These findings appear to overlap in part with the neurobiological underpinnings of violent behaviour in antisocial personality disorder and psychopathy. More detailed investigation of violence in patients with schizophrenia, with appropriate consideration of the relevant co-morbidities, is required to elucidate which deficits, if any, are specific to violence in schizophrenia. A Cruel and Unusual Punishment? -The Psychological Effects of Taser Use on Psychiatrically Vulnerable Adults Dr Elizabeth O‟Mahony, Speciality Registrar, Severn Deanery Dr Ragini Heeramun, ST4 Forensic and Learning Disability, Severn Deanery Dr Mark Bolstridge, Speciality Registrar, Severn Deanery Introduction Tasers came into widespread use in the United Kingdom in December 2008. During the authors time working in a Regional Secure Unit in the South West of England there have been several uses of Taser devices on inpatients. Taser use has been by the Police and at the discretion of the Police and not the medical teams caring for the individuals involved. This has prompted a project to examine Taser use in greater depth. Although information is available on the physical effects of Taser use we were unaware of any work on the impact of Taser use on mental health. We feel that knowledge of the psychological implications is vital for mental health practitioners encountering its use and working therapeutically with the individuals involved. Aims and Method The aim of this project was to review the accessible information on the psychological effects of Taser use. We searched online databases including Embase, Medline, PsychINFO, CINAHL, and BNI. Search terms included Taser, electromuscular incapacitation devise, stun gun, conducted electrical weapon, and non lethal weapons. We also searched for any police information in the public domain and reviewed the material available on the manufacturers‘ website (www.2.taser.com). Results There were many papers on the physical effects of Taser use but there was scant information on the psychological implications of its use. Many papers highlighted the lack of research in this area, and there has been a consistent call for more work exploring the wider consequences particularly in the psychiatric population. However to date we could not find any substantial work in this area completed. Clinical Implication The impact of Taser use on mental health is unknown and there is a lack of substantive research. In view of this we feel Tasers should only be used as a last resort when all alternatives have been exhausted. A discussion also needs to occur about the appropriateness of Taser use on psychiatrically vulnerable adults in the care of Mental Health Services and whether their continued use without medical approval is acceptable. Typifying the Historical, Clinical and Risk management factors in low secure forensic population Authors: Dr Pradeep Pasupuleti MBBS, MRCPsych Dr Pujit Gandhi MBBS, MRCPsych Dr Carlo Thomas MBBS, MRCPsych Dr Tom White BA, BSc (Hons), MB ChB, FRCPsych, Dip FM, MSc Objectives: 1. 2. Method 1. 2. 3. 4. Report on the total HCR scale and individual Historical, Clinical and Risk management subscales in a low secure forensic population Investigate whether there are differences in the C and R subscales between in and out patients and its relationship to First minister‘s patients Case note review of all patients in low sec forensic patients n=67 Background information will be obtained using a pro-forma to elicit background offence and diagnostic variables Study results will be compared with data available from medium and high secure forensic population in Scotland. Analysis of the data will be done using SPSS Results Preliminary data indicate that the historical factors do not vary amongst the three populations, i.e. low, medium and high secure estates. However, there are some differences in the clinical and risk management items. We await full results by end of October 2010. Clinical significance This is one of the first studies on the disaggregated HCR-20 scores. HCR-20 had clinical utility in allowing a systematic identification of substance misuse and personality factors. It is sensitive to change and could be used as a guide to security level. How useful are Medical reports for Care Programme Approach (CPA) meetings in a medium secure hospital? Dr.Prajakta Patil, ST4 (Forensic Psychiatry), South West London & St.George`s Training Scheme, London. Dr.Rajesh Nadkarni, Consultant Forensic Psychiatrist, St.Nicholas` Hospital, Newcastle. Background: NICE(1) recommends that CPA(2) reviews for patients in secondary mental health services should ensure regular physical health monitoring and documentation. This is especially significant in forensic services where patients have lengthy inpatient admissions. Hutton Centre is the regional secure unit for the north-east of England, extending from Teesside to Cumbria, serving a population of 14,74,843.It has 24 low and 55 medium secure forensic beds. Length of inpatient admission ranges from 18 months to 30 years. Aims: This service evaluation looked at the existing processes and quality of information recorded in the medical reports for care coordination meetings. In stage 1, a standard medical CPA proforma (appendix1) was devised following multidisciplinary feedback and piloted for three months. Stage 2 was performed 3 months after implementing changes to practice to evaluate the satisfaction with the process. Methods: Feedback regarding medical reports was sought from 25 members of the multidisciplinary team involved in CPAs over the previous 12 months at the Hutton Centre. This consisted of 2 psychologists, 1 social worker, 16 qualified staff nurses, 4 consultants, 3 specialty trainees in psychiatry. This identified wide variability between medical reports with inconsistent documentation of medication side effects and physical health monitoring on occasions. Based on this, a proforma for medical reports was devised and piloted in the same wards for three months. Stage 2 was completed using a semi-structured questionnaire to evaluate satisfaction with the structured proforma and quality of physical health documentation from the same 25 multidisciplinary staff. Results: Stage 1: Revealed variability in documenting medication, physical health monitoring, and duplication of information in reports across disciplines. Stage 2: 21 staff stated they were ‗very satisfied‘ and 4 were ‗satisfied‘ with the proforma. They reported that it had improved communication between professionals. All felt that the proforma was effective in reducing duplication of information and improving documentation of physical health. Clinical implications: Multidisciplinary staff valued a structured and consistent medical CPA proforma which clearly articulated medication and physical health issues. In our view this is beneficial in reducing duplication of information, improving the quality of medical reports thereby improving the quality of the service. This is particularly important when the focus over the next few years in the NHS is on reducing waste and improving efficiency and quality of care within existing or reduced resources (3). References: 1 2 3 4 NICE guidelines: ‗Core interventions in the treatment and management of Schizophrenia in adults in primary and secondary care‘, March 2008. Care Programme Approach: Department of Health(DoH) http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/DH_083650 NHS Confederation: ―Budget figures reiterate scale of NHS challenge‖, 22June 2010 http://www.nhsconfed.org/Pages/home.aspx.Also,The Times, ―Emergency budget 2010: aggressive cuts will hit growth‖ 22June 2010.Efficiency cuts ‗will hit NHS‘ 23 April 2009; bbc.co.uk, ‗How will recession hit the NHS‘ 10March 2009. Standard proforma for Medical CPA report (appendix 1): • Personal details: Name, DOB • Admission Details: – DOA – Diagnosis – MHA Status – Consultant – Current medication • Background & Circumstances leading to admission (including index offence)-(for the first CPA only) • Progress since last CPA: – Changes in MSE. – Medication changes since last CPA. – Significant changes in biological functioning. – Any other significant events (may include brief overview of OT, leaves, psychology) • Physical Health: – Side effects – General medical complaints/illnesses. – Monitoring for psycho tropics & serum drug levels (if any)-last done & due. – Drug interactions (if any). • Summary: • Points for discussion: • • • • Attached: As guidance on physical examination and medical history relevant in Psychiatry: a) Garden, G.; ‗Physical examination in Psychiatric practice‘, Advances in Psychiatric Treatment(2005)11:142-149; b) Phelan, M; Blair G; ‗Medical history-taking in Psychiatry‘, Advances in Psychiatric Treatment (2008) 14:229-234 Trust guidance on monitoring for high dose anti-psychotics Note: Currently, the trust guidelines for monitoring of antipsychotics at all doses are the same as above. Reduction in repetition with structured proforma: Effective documentation of physical monitoring/general Medical illness: 25 30 20 25 20 15 yes 10 no 15 10 yes no 5 5 possibly 0 0 yes no possibly yes no Looking Ahead: Community Forensic Services at Reaside Clinic, Birmingham Dr Ramneesh Puri ST6 Forensic Psychiatry, Birmingham and Solihull NHS Foundation Trust; Dr Jeremy Kenney-Herbert, Consultant Forensic Psychiatrist, Reaside Clinic, Birmingham; Dr Leela Sivaprasad, Consultant Forensic Psychiatrist, Reaside Clinic, Birmingham. Background: Reaside Clinic has provided community follow up services for mentally disordered male offenders, the majority discharged on restriction orders, for 23 years. During this time adults of working age (AWA) services have undergone major innovation and reorganisation and Reaside Clinic has developed strong but informal links with these services. In the current health economic climate, with necessary increased focus on quality and efficiency, there is an effort to strengthen these links and develop robust criteria and protocols for all stages of mentally disordered offenders‘ care pathways. This is in keeping with the West Midlands Strategic Commissioning Group Secure Services Strategy 2010-2015. Aim: We did a cross sectional survey of all patients being followed up in the community by Reaside Clinic to identify the number of patients, their index offences, their legal statuses and any change in PCT over the years. Results: Numbers: Reaside Clinic had 109 community patients. 2 died of natural causes in weeks preceding this survey. Legal Status: 64% (n=68) were on MOJ restriction orders (including Section 41 and CP(I)A but excluding Section 49 restrictions) either currently or in the past. 13% (n=14) were on Supervised Community Treatment (CTOs) and 24% (n=26) were informal (excluding 10 who were absolutely discharged from MOJ restrictions). Index offences: 30% (n=32) had index offences of ABH, GBH or wounding. 25% (n=27) had murder, manslaughter or attempted murder. 17 % ( n=19) had Sexual offences (including 13 with Rapes). Four had no index offence. PCT; 38% (n=41) had a different responsible PCT from that at the time of admission to Reaside Clinic. Discussion: The above data has already provoked interesting discussions around the question of whose responsibility these complex patients should be and what specifications should the reorganised community services have? These issues are being discussed by a joint working group including Forensic, AWA, Social care, service users and carers and other relevant stakeholders with the aim of further developing the pathway for mentally disordered offenders to optimise care and safety. Assessment of risk of violence; a clinical audit of community addiction service. Dr Sobia Rafi –CT3 Trainee Dr Mosun Fapohunda-Specialty Registrar Dr Vijaya Murali-Consultant Psychiatrist Azaadi Community Drug Team, Birmingham and Solihull Mental Health Foundation Trust. Aims: Illicit substance use is known to be associated with a variety of risks. This include risk to self, others and potential for aggression/violence. Carrying out a thorough assessment of risk of violence in this client group, is not only an essential component of good psychiatric practice, but also necessary in order to manage the risks appropriately. The Royal College of Psychiatrists gives guidance about what is required in these assessments. We aimed to establish current practice of assessment of risk of violence within our team, and make recommendations for improvement. Methods: A retrospective review of case notes of 31 new referrals to our team between January-September 2010 was carried out to gather the required information. Results: The recording of a risk assessment statement (i.e. low, medium and high) was documented in only 3/31 notes, though risk management plan was seen in 30/31 notes. Forensic history was documented in 29/31 of the assessments. Psychiatric co morbidity was seen in 25% of the sample. Collateral information from other professionals was only available for 4 clients. 48% had spent time in prison for offences like theft, assault and violence (25%). Also noted was the neglect of attention to clinical enquiry regarding recent and ongoing violent thoughts. Aggressive ideation regarding damage to property and interpersonal violence was also not recorded in any of the notes. Conclusion: Our results show that risk management plan was documented in almost all the notes, but details of the identified risks that informed this management plans were scanty. The assessments could be made more comprehensive by adding a few salient questions about the current violent thoughts and ideation which would be helpful in making the risk assessment more thorough. We hope to train all staff working in our team on the assessment of risk of violence and carry out a future re-audit. Audit cycle of Antidepressant prescribing at The State Hospital Scotland: Dr Ayesha Raja, Speciality doctor Dr Ian Dewar, Consultant Forensic psychiatrist Sheila Smith, Clinical Effectiveness. Introduction: The State Hospital is a high secure hospital providing care and treatment to people who need to be detained under conditions of special security. It is situated in Scotland and covers Scotland and Northern Ireland population, currently housing 140 patients. An audit was carried out in 2009 looking into the prescribing of antidepressants at The State Hospital. This was part of the audit cycle originally carried out in 2006. Aim: 1. 2. Compliance with prescribing standards - Lothian Joint formulary Looking at the documented reasons for prescribing antidepressants Standards No more than one antidepressant should be prescribed to a patient at any one time. Dose should not exceed BNF maximum dose. SSRI‘s should be used as first line therapy in accordance with the NICE guidelines. Method: Sample included all the patients (16) on antidepressant therapy in October 2009. The audit tool was developed looking into prescribed antidepressants, dosages, frequency, total daily dose, commencing date, reason for prescribing Antidepressant and other medications used. Results were compared with the audit in 2006. Results and Recommendations 1. Percentage of patients prescribed antidepressants in 2009 had fallen in comparison to 2006 (11% as opposed to 14%). This is in accordance with national target set by Scottish government. 2. No patient was prescribed more than one antidepressant in 2009 or 2006 audit 3. No patients exceeded the recommended British National Formulary guidelines dosages in 2009 or 2006 audit 4. SSRI‘s was the most commonly prescribed antidepressant medication in both the audits (81% in 2009 and 76% in 2006) 5. Citalopram was the commonest SSRI in both 2009 and 2006 (45% and 31%) 6. Reasons for prescribing Antidepressants: Explicit reasons were documented for 67% of patients in 2009. This was an improvement since the audit in 2006 when 52% of patients had explicit diagnosis given. 73% of patients were prescribed antidepressant for depression and 18% for anxiety in 2009. 72% of patients were prescribed antidepressant for depression and 24% for anxiety in 2006. Within the hospital it is policy to review patient‘s mental state and medication at a regular interval. Implementation of this as a part of treatment plan will ensure a more structured format for documenting explicit reasons. An Inclusive Community Service for Mentally Disordered Offenders – Scoping Exercise Author: Dr. Lakshmanan Ramachandran, MRCPsych, StR6, Forensic Psychiatry, Mersey Care NHS Trust, Liverpool Co-authors: Dr. Claire Brabbins, MRCPsych, Consultant Psychiatrist, Mersey Care NHS Trust, Liverpool Introduction: Treatment needs of mentally disordered offenders within secure care are complex. Secure NHS inpatient beds are few. Private Sector Secure inpatient beds are often used, even if out of area (Out of Area Treatments / ‗OATs‘). The above services remain variously cost effective but, in general, are accepted as expensive. With focus now on reducing costs and maximising savings there is scope for setting up innovative cost effective services within the NHS for this subgroup of service users. Aims: Explore possibility of setting up an inclusive / integrated community mental health service for mentally disordered male and female adult service users, currently within secure inpatient units, in Northwest England. Method: Focus group was held to clarify the structure, priorities, functions and financial implications of the intended service. Electronic patient records serve as sampling frame as well as database for this exercise. All service users from the NHS trust‘s catchment area, currently placed in ‗out-of-area‘ low secure units (OATs) were identified. Case summary of each service user identified was examined. Data was extracted to identify treatment needs [medication; psychology; nursing; social support; special needs (deafness; acquired brain injury etc); public protection / security], legal status, risk profile and Offending behaviour. Results Of the 40 (N) service users (31M; 9F) 22 were admitted under secure units for mentally ill; 10 under specialist personality disorder units; and 8 under specialist learning disability units. 2 service users are deaf; 5 have acquired brain Injury (ABI) and none have a diagnosis of Autistic Spectrum Disorders. A number of them have significant physical health problems ranging from disabling cardio respiratory illness to metabolic syndromes. Work is now underway to elucidate the offending profile and risk profile of the individual patients and the exercise will be completed by November 2010. Conclusions: There are likely to be significant financial and practical challenges in setting up this community service. Physical health needs, nursing needs; risk management needs in general as well as in specific offences (for e.g. sexual offending) appear significant in this respect, hitherto. A seamless interface between this inclusive community service, other local specialised community mental health services and criminal justice system is required but may be harder to achieve. Nature and Prevalence of Various Organic Mental Disorders in a Medium and Low Secure Neurorehabilitation Service Dr Vishwanath Byregowda Ramakrishna, MBBS MRCPsych LLM, Consultant Forensic Psychiatrist, St. Mary‘s Hospital, Warrington Introduction Some patients with Organic Mental Disorders require compulsory care and treatment in specialist secure/forensic settings due to their risk history and specific neurorehabilitation needs. Such patients are usually diverted from courts or admitted from other psychiatric or Brain Injury rehabilitation services. There is a paucity of research regarding the type of patients who require such specialist secure services which are mostly available in the independent sector. Such information is important for effective service provision within existing NHS/Independent Sector facilities or development of new specialist services. Aim To determine the nature and prevalence of various Organic Mental Disorders within a Secure Neurorehabilitation Hospital. Method This was a point prevalence study including all inpatients in the Medium and Low Secure Neurorehabilitation Units of an Independent Secure Hospital located in the Northwest of England. Demographic details, MHA section, and ICD-10 primary diagnoses of all patients was collated from medical records and analysed. Results A total of 39 patients were detained in the Medium (41%) and Low Secure (59%) Units under various sections of the Mental Health Act 1983 (amended 2007) (s3: 51 %, s37/41:18%, s37:18%; s 48/49 and s38:5%) and Section 5(2) of the Criminal Procedure (Insanity) Act 1964 (amended 2004) (8%). The age range of patients was 23 to 64 years (Mean: 40.7 yrs). The primary diagnoses of patients included Organic Personality Disorder (44%); Organic Personality Disorder with Organic Delusional Disorder (13%); Organic Personality Disorder with Organic Amnesic Disorder (5%);Organic Personality Disorder with co-morbid mental illness (Paranoid Schizophrenia/Bipolar Affective Disorder 8%); Dementia in Huntington‘s Disease (5%);Frontotemporal Dementia and Paranoid Schizophrenia (2.5%); Paranoid Schizophrenia with Frontal Lobe impairment (8%); Other specified or unspecified mental disorder due to brain damage and dysfunction and to physical disease (Hydrocephalus, epileptic psychosis 8%); and Alcohol Induced Dementia (2.5%). Two patients were recently admitted and were still undergoing assessment and a formal ICD10 diagnosis was yet to be made. Conclusion The most prevalent disorder was Organic Personality Disorder (70%) either present on its own (44%) or with other co-morbid conditions (26%). This included individuals with no previous psychiatric history (62%) or those with pre-existing mental illnesses (8%). Challenging/offending behaviours in patients with neurological/neurodegenerative diseases, dementia (including alcohol induced), and chronic mental illness with executive dysfunction had necessitated admission to this secure specialist service in the rest (30%) of the cases. Service User Satisfaction in a Regional Forensic Medium and Low Secure Service Dr Steve Ramplin and Dr Phillip Brown Introduction There is evidence that satisfaction with care delivery leads to an improvement in health status. Levels of user involvement and satisfaction are central to Government policy in health service provision and user satisfaction is recognized as a valuable measure in evaluating the performance of NHS services. The few studies completed on user satisfaction in secure forensic settings contain limited qualitative data. However, results of previous studies suggest patients detained in a medium secure unit are able to report on satisfaction with their care. Aims This project aimed to audit user satisfaction across a regional forensic medium and low secure service. A questionnaire was designed to anonymously capture demographic information and patients' views about their psychiatrist, meetings, care and treatment. Methods After ethical approval was received a presentation about the project was given to ward managers and service user representatives for dissemination to the patient population. The questionnaire was then piloted with service user representatives. In March 2010 it was distributed to 93 inpatients with the assistance of the Patient Advice and Liaison Service, who facilitated completion of surveys upon request. Completed surveys were posted into collection boxes on each ward. Results Forty-nine patients (51.6%) returned completed surveys. 85.4% were male, 89.6% were white and 43.9% were detained on a civil section. Age appeared normally distributed. A primary psychotic diagnosis was reported by 57.1% and a primary diagnosis of either personality or mood disorder by 14.3%. Current mental health was rated 'Very Good' or 'Excellent' by 56.3%. Patients were generally satisfied with their psychiatrist, although 59.6% felt they had insufficient time to discuss their care, a concern echoed in qualitative comments. 78.7% of patients were usually invited to their CPA meetings, with most feeling able to participate. Qualitative data highlighted concerns about too many attendees and patient involvement appearing tokenistic. All respondents took medication. A majority (55.8%) understood its role but only 28.9% felt side effects had been adequately explained. Psychological interventions and physical health care were generally well received. 60% were not interested in preparing an Advance Statement. 41.9% felt their Mental Health Act rights had been completely explained. The results are comparable with equivalent data in the Mental Health Acute Inpatient Service Users Survey 2009, although performance was poorer in the 'enough time to discuss condition and treatment' domain and better in terms of explaining the role of medication and physical health management. A Case Report of Body Integrity Identity Disorder in a forensic inpatient Primary Author: James B. Reynolds, M.D., F.A.P.A., Medical Director and Chief Forensic Psychiatrist, Northwest Missouri Psychiatric Rehabilitation Center, Missouri Department of Mental Health, St. Joseph, Missouri, U.S.A. Second Author: Roxanne C. Keynejad, B.A. (Hons), 3rd year GPEP MBBS Student, King‘s College London, U.K. Body Integrity Identity Disorder, or Amputee Identity Disorder, is a rare syndrome characterised by the persistent and intense desire to have an apparently functional body part amputated, usually an arm or leg. Similar ideations are seen in Body Dysmorphic Disorder, Somatophrenia, and Apotemnophilia. This case report discusses a 41 year old right-handed Caucasian male, Mr G, who is detained in a low secure forensic facility in Northwest Missouri under Not Guilty by Reason of Mental Illness status for a sexual offence. The patient recently disclosed the desire to have his functional right arm amputated. Mr G suffers from osteogenesis imperfecta resulting in a moderately bowed and slightly shortened, but fully functional, right forearm. The arm is not dramatically misshapen, and appears essentially normal unless closely inspected. After a four year admission unremarkable for right arm complaints, the patient confided to the hospital chaplain that he had wished his arm to be amputated since a traumatic event eight years ago when his house burned down. He now refrains from using his right arm in order to ―practise‖ for being an amputee. Mr G‘s primary diagnosis is Schizophrenia, Paranoid Type, but his ideations about his arm are unrelated to his psychotic illness, which is apparently well controlled on Risperidone and Sertraline, with no evident delusions about his arm. Mr G‘s chief complaint is that he feels ―less of a man‖ with his right arm and believes his self-esteem will be greatly enhanced by being ―made whole‖ when it is cut off. The authors are unaware of any documented cases of this syndrome in a forensic patient and the research base is sparse. The authors explore the existing literature, compare this case with the diagnostic criteria proposed for this disorder and discuss the ethics of treatment for this condition by elective amputation of a functional and generally healthy limb. Parental Representations in a Forensic Personality-Disordered Population Dr Lucinda Richards CT1 Psychiatry Trainee, South London and Maudsley NHS Trust. Dr Gill McGauley (Supervisor) Consultant and Reader in Forensic Psychotherapy, Broadmoor Hospital; West London Mental Health Trust and St George‟s University of London Introduction Research shows that adverse parenting affects child development and contributes to the development of psychopathology such as personality disorder in adulthood. In particular, perceptions of early parental attachment figures, in part, determine the nature of adult interpersonal relationships. Forensic, personality-disordered patients have frequently experienced early adverse parenting and their personality disorder manifests itself, most often, in disordered adult relationships with staff and other patients which can interfere with their treatment and progress. The parental attachment representations of this group are under-investigated. Aims This research investigated parental representations in a sample of personality-disordered forensic patients in Broadmoor High Secure Hospital to determine whether, and if so how, these representations differed from those in other populations. Methodology Analysis of self-report questionnaire data and comparative literature review. Data from the Parental Bonding Instrument (PBI) was analysed from 66 patients with a research diagnosis of personality-disorder. Means and standard deviations for each of the 2 PBI dimensions (parental care and control) were extracted from representative studies from the literature review. Differences in means, between studies and Broadmoor patients, were calculated using independent t-tests. Results The literature review yielded 110 papers. Compared to both the non-clinical and the clinical groups, the Broadmoor patients scored significantly lower for both maternal and paternal care indicating that the Broadmoor patients perceived their relationship with both parents as lacking in care compared to other psychiatric patient groups. Interestingly, the forensic patients perceived their parental care as significantly poorer than their non-forensic personalitydisordered counterparts (p ≤ 0.05). The study group scored significantly higher with respect to both maternal and paternal control compared to all normal groups (p ≤ 0.001) but not compared to the other clinical groups. Conclusion Compared to non-clinical individuals the Broadmoor patients perceived their parenting as falling into the most adverse domain; lacking in care and highly controlling. Despite similar psychopathology, perceived experience of care appeared to discriminate between the forensic, personality-disordered patients and non-forensic patients. This further supports the clinical observation that forensic, personality-disordered patients have experienced early adverse parenting and suggest that it is perceived experiences of poor care that may be particularly relevant in forensic personalitydisordered patients, rendering the child susceptible to later developmental psychopathology. Knowledge of the parental representations of forensic personality-disordered patients may provide professionals with a handle on understanding how these can contribute to their adult interpersonal interactions during treatment and ultimately inform therapeutic interventions. AUDIT OF THE TRANSFER OF PRISONERS FROM HMP ISLE OF WIGHT TO MENTAL HEALTH HOSPITALS Dr Tamsin Peachey, Forensic Psychiatry trainee (ST5) & Dr Luke Birmingham, Consultant Forensic Psychiatrist, Ravenswood House, Fareham, Hampshire Objectives: 1. Review time taken to transfer mentally disordered prisoners to hospital. 2. Identify where and why delays are occuring locally. 3. Recommend changes to practice to reduce delays. Background: A prison is not equipped to deal with acutely unwell people and the Mental Health Act (2007) does not apply in prison. It is, therefore, vital that mentally disordered prisoners be transferred, without delay, to a mental health hospital with an appropriate level of security. In a recent report (Prison Reform Trust), a large number of prison boards reported significant delays in this process. The Bradley Report, an independent review, suggests the process should be complete within 14 days. Methodology: A database has been compiled by the Community Mental Health Team (CMHT) at HMP Isle of Wight on all prisoners referred for transfer to a mental health hospital. As data did not follow a normal distribution, median values provide a better description of the data. Medians with lower and upper interquartile ranges are given (within which 75% of the sample and 25% of the sample fall, respectively). Results: Between November 2005 and October 2009, 121 prisoners were referred for transfer to hospital due to their mental state. Of these, 77% were accepted for admission. The median transfer time from referral to admission (n = 70) was 140.5 days (IQR +/62.5 - 200). The median time between 1) initial request by prison/CHMT to assessment by prison psychiatrist (n = 96) was 5 days (IQR +/- 1 - 7); 2) referral to assessment by hospital (n = 81) was 49 days (IQR +/- 21 - 79); 3) assessment to acceptance by hospital (n= 50) was 13.5 days (IQR +/- 3.5 - 32) and 4) acceptance to admission (n = 47) was 24 days (IQR +/- 10 - 57). The number of prisoners meeting Bradley‘s recommendation of 14 days is one. Conclusions: Preliminary analysis of the database has confirmed that we are falling short, by a large margin, of the 14 day transfer time suggested by Bradley. Unacceptable delays occur at each stage, the largest being time between referral and assessment. We need to assess what accounts for such delays and what factors (eg, diagnosis, level of security, catchment area) have a bearing on transfer times. This will inform practice to address and reduce delay. Evaluation of court diversion scheme at NHS Forth Valley by Forensic Community Mental Health Team Roy MBBS MRCPsych;Dr. Rhona Morrison MBChB ,MRCPsych. Dr.Peeyush Aim: To evaluate the activity of court diversion scheme of NHS Forth Valley performed by Forensic Community Mental Health Team. Method: A retrospective analysis of data collated over period of last three years, looking at characteristics of referrals, diagnosis and their outcomes. The Forensic Community Mental Health Team covers a general population of approximately 300,000 and provides court liaison service to three Sheriff Court in that region. Results: A total of 139 referrals were received from 2007 to 2009. Significant higher proportion were male within the age range of 20 -29 and were homeless. The single most common offence was of public order i.e. Breach of Peace followed by violent assaults. Over the three years there is gradual increase in referrals. Alcohol was frequently associated with the index offence accounting for 29.6 % (2009), 42.2 %( 2008) and 52.5 %( 2007). Assessment of Fitness to plead was the most common reason for referring the defendants, which accounted for 55.5% (2009), 71.1 %( 2008) and 52.5 % (2007).The second commonest reason was for ―bizarre behaviour‖. Most common Diagnosis at the time of assessments alcohol related behavioural and mental disorders followed by Personality Disorder. Following majority of assessments there was ―No Recommendation‖ made, 50 %( 2009), 46 %( 2008) and 40 %( 2007).Formal admission was recommended on average of 12% of all referrals each year. In terms of final outcome significant numbers were granted bail, 37 %( 2009), 51.1 %( 2008) and 40 %( 2007). Recent report Diversion: a better way for criminal justice and mental health suggested that although diversion can reduce the risk of unnecessary imprisonment and reoffending, only 20% of people with mental health problem can avail these schemes. The above study reinforces the evidence that diversion works especially well for people who have committed relatively minor offences from serving short prison sentences. There is a provision to consider improvement in these services in future to prevent mentally ill offenders getting entrapped within the criminal justice system. ELDERLY HOMICIDES- CALL FOR A NATIONAL DATABASE IN UNITED KINGDOM: A Literature Review and Case series Dr.Sabarigirivasan Muthukrishnan MRCPsych; Prof.Graeme Yorston MRCPsych; Dr.Suchitra Sabarigirivasan MRCPsych AIM The aim of the research is to understand the psychiatric and psychosocial aspects of elderly homicide offenders with a view to develop risk assessment tools, risk prediction tools and risk management strategies. METHODS A: Review of medical literature on Elderly Homicides in UK and other countries. B: Review of medical literature and relevant home office published literature to understand the various national databases in UK, where the homicides are recorded and also to understand how murders committed by elderly and elderly mentally unwell offenders are recorded C: A case series which studied the psychiatric and psychosocial aspects of 12 elderly psychiatric patients who committed murder and have been either admitted to a low secure elderly men and women unit in UK or referred for opinion. RESULTS In UK, the research is not very promising in relation to Elderly Homicides. There are many studies from US but due to various factors the results of those studies are not applicable in UK .There is less promising recording of the details of Elderly Homicides in UK national databases which record homicides. The current existing databases in UK do not separately delineate the characteristics of elderly homicide offenders which can be a challenge to interested researchers. The case series of 12 patients in the low secure facility for elderly men and women, showed that there is room for improvement in the way elderly homicide data on offenders and victims are collected and shared among different agencies. The literature review and case series showed that Dementia, Depression and Psychosis were the common diagnosis implicated in Elderly Homicides. We couldn‘t come up with the risk assessment tools, risk prediction tools and risk management strategies with the literature review and study of the various databases. We were able to identify the most relevant psychosocial characteristics of elderly homicide offenders and the common psychiatric diagnosis implicated. We are able to recommend the way forward for research in this patient group to come up with the risk assessment/prediction tools and management strategies. RECOMMENDATION The research on elderly homicide can be done effectively if there is a separate national database which records the details of Elderly Homicide offenders and victims. Alternatively, the current national databases on homicides can record effectively the details of elderly homicides. This will help the health care agencies, social care agencies, criminal justice service and other voluntary agencies involved with elderly homicide offenders and their families. An Exploration of Physical Health in a Forensic Rehabilitation Setting Mr Rishi Sen, Mr Jaison Patel (medical students) and Dr Elizabeth van Horn (Consultant in Forensic Rehabilitation) Introduction Numerous studies have shown that the physical health of forensic mental health patients is generally poor. The long stay patient group has even higher rates of morbidity and mortality. There are many possible factors contributing to this, such as poor awareness of physical health issues within the care team. This is an area that has received greater attention over recent years. Our aim was to examine the physical health care of one patient group. Method An audit was carried out based on the ―Physical Healthcare Guidelines‖ provided by the East London and the City Mental Health Foundation Trust‖. This was introduced earlier this year. This recommended recording the blood pressure, pulse, weight, waist circumference, lipids, U&E, fasting blood sugar, HBA1c, FBC, LFT, TFT,ECG , prolactin and therapeutic drug monitoring within a set interval period for each. We assessed how closely these guidelines were followed e.g. ECG done annually. We hoped that this would be a good indicator of whether the patient's medical needs were being met. Clinical notes were audited and the results fed back to the care team. Six weeks later a repeat audit was carried out. We then ran a focus group for the staff to identify areas of improvement. Results The initial audit showed that less than 30% of the criteria were met within the set time period. The most recorded were ECG, blood pressure, pulse and weight, and the worst recorded where HBA1c, liver-function-tests, thyroid-function-tests and prolactin. The repeat audit showed a higher level of met need. Staff had used a variety of innovative and creative methods to enlist patients in their physical health care. Conclusion We concluded that a large proportion of the physical health criteria were not met, despite the best intentions of the team. We also noted that some investigations had been carried out but had not been recorded in the clinical notes and felt that this reflected problems in shared care with local GPs. The focus group identified a number of factors which increased the quality of care provided. This included close Consultant supervision of Junior Doctors. In addition staff had been able to use their considerable expertise to motivate patients to take responsibility for their health. Use of Granulocyte Colony Stimulating Factor in Clozapine induced Neutropenia Dr Jake Harvey, Speciality Registrar in Forensic Psychiatry Dr Al Aditya Khan, Speciality Registrar in Forensic Psychiatry Dr Samrat Sengupta, Consultant Forensic Psychiatrist, Broadmoor Hospital Background Neutropenia and Agranulocytosis are known side effects of Clozapine treatment. Several studies have reported the use of Granulocyte Colony Stimulating Factors (G-CSF) in haematological, oncological and transplant disorders. However, reports on the use of G-CSF in cases of Clozapine induced neutropenia are somewhat limited. Aim This is a case series report on three patients, all with a history of Clozapine-associated neutropenia, managed with G-CSF and continued treatment with Clozapine with a significant reduction of violence towards others. Method The cases in this study are male patients with a diagnosis of paranoid schizophrenia detained in a maximum security psychiatric hospital with a history of poor response to first-line antipsychotic medications. Furthermore all had previously responded well to Clozapine thereby significantly reducing their risk of harm to others. However, all experienced neutropenic reactions leading to discontinuation of Clozapine. Two patients also had a history of idiopathic cyclical neutropenia, in the absence of Clozapine. They were given doses of G-CSF prior to Clozapine re-challenge, due to low baseline neutrophil counts. Clozapine was subsequently restarted following return of normal Neutrophil count, with enhanced blood monitoring. The third patient with a normal baseline neutrophil level received G-CSF following a low neutrophil count. Results All three patients have experienced reduction in symptoms with a significant reduction of violence towards others, and improvements in quality of life. Furthermore none has experienced adverse drug reactions related to G-CSF. Conclusion This study demonstrates the clinical utility of an alternative approach to discontinuation of treatment following Clozapineassociated neutropenia in patients with treatment resistance intractable Schizophrenia, whose risk of violence to others had been related to their psychotic symptoms. While this approach is not recommended as first-line, it highlights a potential avenue for patients associated with significant risk profiles. Testing an innovative way of information dissemination in a secure hospital: Awareness Roadshows Dr Amit Sharda CT2, Dr Potoula Sykioti CT3, Dr Kunal Choudhary CT2, Ruth Neilson (Occupational Therapist), Dr Mrigendra Das Consultant Forensic Psychiatrist, Broadmoor Hospital, Crowthorne, Berkshire, UK Background Broadmoor Hospital has been subject to two recent major inquiries. The CQC inquiry was following concerns the Trust were not learning from serious incidents. The PB-RL inquiry followed the inpatient homicide of a patient by another patient at Broadmoor Hospital. These inquiries revealed a number of findings leading to a series of recommendations that needed implementing. The hospital underwent a programme of changes aiming to improve standards of patient care. To carry out these changes effectively it was felt to be crucial that ward staff were actually aware of these the post-inquiry recommendations. Aims To find out whether staff knowledge and awareness surrounding these inquiries was sufficient. If staff knowledge was deficient, to implement an effective way to improve knowledge and awareness. Method A questionnaire was designed to assess staff awareness, and knowledge of findings, recommendations, and changes implemented in the hospital following these inquiries. Staff opinion was also sought surrounding confidence of role, their perception of change occurring, and morale, as well as space for comments. We interviewed 45 ward based staff. Staff knowledge was found to be deficient in most areas. Qualitative analysis also fed back that there was not enough face to face contact surrounding these, and that too much information was contained in the reports. In light of these findings, an intervention was planned. Feedback showed it had to be succinct and relevant to the ward staff. Time and cost were also important factors. Information from the inquiries was summarised and grouped under relevant headings. This information was then put into an ―awareness roadshow‖ presentation lasting 10 minutes and consisting of eight slides with handout. Three junior doctors then went to the same three wards and ran the roadshows during nursing handovers and MDT meetings. The same questionnaire was then repeated to 45 staff who attended the roadshows to complete the audit cycle. Results Staff knowledge and awareness increased appreciably following the roadshows. Awareness of the CQC and PBRL inquiries jumped from 44% and 82% respectively to 93% and 100%. At least partial knowledge of recommendations increased from 40% to 98% and partial knowledge of changes increased from 43% to 95%. Conclusions A simplified, succinct, face to face, time effective intervention (Awareness Roadshows) was successful in information dissemination. Every staff member interviewed felt the roadshows were useful and that they should be used to disseminate similar pieces of information in the future. This method can be adapted in other parts of the NHS and particularly by High Reliability Organisations where failures of standards are unacceptable. Smoking restrictions in secure psychiatric units – The medium secure experience Dr Suraj K Shenoy, MB BS, MD, MRCPsych; ST5 in Forensic Psychiatry; Humber Centre for Forensic Psychiatry, Willerby, Hull, HU10 6ED [email protected] Dr John H Kent MB BCh, FRCPsych Consultant Forensic Psychiatrist Newton Lodge, Yorkshire Centre for Forensic Psychiatry, Ouchthorpe lane, Wakefield, WF1 3SP Mr John Wiggins Clinical Security Manager Newton Lodge, Yorkshire Centre for Forensic Psychiatry, Ouchthorpe lane, Wakefield, WF1 3SP Aim The restrictions on smoking in health services within England and Wales, both for NHS and independent providers, including secure psychiatric units has been in force since July 2008. The introduction of these restrictions led to considerable debate within our medium secure hospital on the practical issues of implementing a smoking ban. We surveyed all the NHS and Independent sector medium secure units in England & Wales to find out their experiences of the introduction of these restrictions. Method We attempted to contact every medium secure unit within NHS and the independent sector in England and Wales to ascertain the person best placed to respond to our survey. The survey was set up on a specialist survey website. A request to participate in the survey along with a link to the user friendly survey was sent by email to the relevant person identified. Results 39 medium secure units responded to the survey. The analysis of the responses shows that there has been considerable variation in the extent to which the smoking restrictions have been implemented. The results highlight some major adverse consequences caused by the practical implications of introducing restrictions on smoking as opposed to a total ban on smoking. Conclusions Implementing a smoking ban requires considerable planning and has resource implications to manage potential serious adverse consequences. CLINICAL PROFILE OF FOREIGN NATIONAL AND BRITISH PRISONERS AT HM PRISON BRIXTON: A COMPARATIVE STUDY Main author Dr Jagmohan Singh Specialty Doctor in Forensic Psychiatry HM Prison Brixton, London Co-authors Dr Andrew Iles Specialty Registrar in Forensic Psychiatry HM Prison Brixton, London Miss Manuela Jarrett Researcher Institute of Psychiatry, King's College London Dr Piyal Sen Consultant Forensic Psychiatrist and Associate Medical Director St Andrews Healthcare, Visiting Research Fellow, Institute of Psychiatry, UK Dr Andrew Forrester Consultant and Honorary Senior Lecturer in Forensic Psychiatry HM Prison Brixton and Institute of Psychiatry, King‘s College London Background The prevalence of mental disorder amongst the prison population is high: previous surveys have reported a two-fold to four-fold excess of psychotic illness and major depression and about a ten-fold excess of personality disorder compared to the general population. Despite evidence that immigration origin is a risk factor for psychological morbidity and suicide in prisons, the clinical profile of the foreign national population has not been studied properly. Aims To describe and compare the clinical profile of foreign national and local prisoners referred to mental health team at a busy London remand (pre-trial) prison. Methods We used a mixed prospective and retrospective data collection method. We surveyed each consecutive referral to the prison inreach team using a template designed to capture the following data: demographics, index offence(s), status (remand, sentenced etc), forensic history, psychiatric history, medical history, co morbid substance misuse, location in prison, source and reason for referral and outcome of the referral. We gathered the data during the initial assessment interview and from collateral sources including: the referrer, the in-reach referrals‘ register, the prison medical records, and the prison custody office. We corrected inconsistencies between self-reports and collateral information. Results 109 referrals were received over a 4-month period. 20 of these were foreign nationals. We found that foreign nationals were under represented in the in-reach referral pool in comparison to their proportion within the normal prison population (18 (n=20/109) vs 40 (HMP Brixton, 2006 statistics)). A greater proportion of the foreign national group had an affective disorder (n=4/20) and a disorder due to substance misuse (n=4/20) compared to the British group (n=11/89; n=13/89 respectively). Proportionately, fewer of the foreign national group were known to community services (n=7/20 vs n=61/89). Conclusions and implications Research on foreign national prisoners is still in its infancy worldwide. This group has significant under-recognised treatment needs. The study findings reflect this problem. Barriers to treatment include: cultural attitudes to mental illness, access to language interpretation services, lack of cultural awareness within prisons, immigration status and possible institutionalized discrimination. We believe that the provision of adequate interpreting services, cultural awareness and mental health education programmes for prison staff would provide the opportunity for earlier detection of mental illness and identification of associated treatment needs. Follow-up studies should also include interviews with foreign national prisoners for a qualitative assessment of their own experience. A service evaluation of the provision of care by ethnicity at Ashworth Hospital, a high-secure hospital Dr Victoria Sullivan (CT3), Dr Edward Silva (Consultant Forensic Psychiatrist) Dr Inti Qurashi (Consultant Forensic Psychiatrist) Background Ashworth Hospital is one of the three High Secure Hospitals serving England and Wales with approximately 210 inpatients. In recent decades deaths within forensic settings have attracted suggestions of institutional racism, and have been a particular concern within the High Secure Hospitals. An audit carried out in 2006 at Ashworth Hospital found that patients from a non-white background perceived that their cultural needs were inadequately assessed and met. The Race Relations Act requires of NHS Trusts that they allow all patients the same access to services and information, regardless of ethnicity. Aims The service evaluation aimed to assess if there were any differences in the each of the following aspects of care for different ethnic groups; Admissions and referrals Length of hospital stay Discharge and trial-leave rate Number of incidents Use of seclusion Access to psychological therapies Method Any person who was an in-patient at Ashworth Hospital at any point between 1st April 2008 and 31st March 2009 was included. Ethnicity was taken as the patient‘s self-ascribed ethnicity and was coded according to national ethnicity codes. Further information was taken from PACIS; the electronic notes system, DATIX; the incident-reporting system, the seclusion monitoring group and the psychology department. Results were analysed using PASW version 18. Results 228 patients were included in this evaluation, 24.6% of whom were from an ethnic minority background. 17% referrals and 22% admissions to the hospital were for patients from a non-white background. Patients from a black background had the longest average length of stay at 8.15 years, with the average for all patients being 7.39 years (p=0.674). 13.5% white patients compared to 5.6% non-white patients were discharged from the hospital, but the results were not statistically significant Leave rates were comparable at 7.6% and 7.4% respectively. For all types of incident, white patients were more commonly the perpetrator, but seclusion rates were highest in non-white patients (37% vs. 26.3%) (p=0.8). Patients from an Asian background had less access to some psychological therapies (p=0.55). Discussion Ashworth hospital has a higher proportion of ethnic-minority background patients than the national average. There is no significant evidence that patients from ethnic-minority backgrounds have different access to services at Ashworth, however there are some differences in length of stay, rate of discharge, rates of seclusion and access to psychological services. Further study with higher numbers of patients is recommended. Prescribing of antipsychotic medication in a regional secure unit-Results of a repeated audit cycle Dr Mujahid Ali Syed, Speciality Trainee, Dr Thomas Elliott, Associate Specialist, Dr Paul Chesterman, Consultant Forensic Psychiatry, North Wales Forensic Services Aim This annual Audit, now in its third year was repeated in Ty Llywelyn Medium Secure Unit to examine the extent to which prescribing of these drugs reflects current evidence of clinical practice, to encourage the development of best practice guidelines and to stimulate a discussion of the relevance and desirability of agreed clinical protocols. Method A point prevalence of prescribing practices within Ty Llywelyn was performed on 14th of August 2009. This was the third repeat collection of prescribing data, collecting the same data as previous audits. Data was collected for all prescriptions of psychotropic drugs. Medication prescribed on as required basis was not taken into account. Results Out of 22 patients only 14 were receiving antipsychotic medication (64%) on a regular basis. Between them they were prescribed a total of 17 regular antipsychotic drug prescriptions. Many of the residents were prescribed only one antipsychotic drug, 11 of 14 (78.6%).Three patients were receiving more than one antipsychotic drug and all three of them were on combination of oral and depot antipsychotics. No patient was receiving regular treatment with more than two different preparations. The majority of patients, 11 of 14 (78.6%), were receiving depot preparation and none of them was receiving a dose below the recommended lower limits thus reflecting maintenance regimes. A minority, 3 of 14 (22%) were on oral preparation alone and none of them were on a lower dose than the recommended minimum. Olanzapine was the most frequently prescribed among atypicals and also the only oral medication being used in conjunction with a depot. Conclusion Atypical antipsychotics were prescribed to 7 of 14 patients (50%), this is almost similar to previous audit in 2006 where 10 of 18 patients (55%) were prescribed atypicals. Only 2 of 14 patients (compared to one in 2006) were on Clozapine. We have generally adhered to BNF recommendation in both audits with regards to prescribing more than one antipsychotic at the same time. Following Nice guidelines only 2 of 14 (14%) patients were prescribed a combination of atypical and typical antipsychotics. No patient was receiving treatment above BNF or Maudsley limits, this is an improvement from previous audit. In accordance with The Royal College of Psychiatrists Consensus Statement no patient had ―mega doses‖ of antipsychotics in either of the audits. Analysis of Incidents in low secure forensic services pre and post reconfiguration Dr Anand Vemula, Staff Grade Psychiatrist, 5 Boroughs Partnership NHS Foundation Trust, Dr Ros Tavernor, Consultant Forensic Psychiatrist, 5 Boroughs Partnership NHS Foundation Trust, Ian Stirton-Cook, Forensic Operational Business Manager, 5 Boroughs Partnership NHS Foundation Trust. Aims: Previous research has highlighted ward environment change as a destabilising factor in patients. It was observed that when Chesterton Unit, a low secure rehabilitation unit at Hollins Park Hospital was reconfigured as an all female unit that there was an increase in incidents in both the male patients who moved to a new 10 bedded male unit and the female patients who remained on the Chesterton unit. The reasons for this are not clear. The aims were to try to identify what factors were associated with the increase in incidents and what interventions may have prevented or reduced this phenomenon. An awareness of the nature and distribution of incidents may improve proactive targeted interventions to minimise risk in future service reconfiguration. Method: The total number of incidents per month was recorded as part of incident reporting for the 6 months before and 6 months after the reconfiguration. To try to establish why the observed increase occurred the incidents were analysed and any generalisations or lessons to be learned for service reconfiguration in the future were identified. Results: Incidents were subdivided into: 1 behavioural disturbance includes - sexual disinhibition, intimidation, threats 2 breach of security – absconding, smoking in non-designated areas, fire risks 3 Physical health problems 4 other recorded events including e.g. medication errors In the 6 months prior to the move the baseline incidents were collected on Chesterton (mixed Unit) and in the 6 months after the number of incidents increased almost fourfold on the Chesterton and trebled on Marlowe unit when the average per patient was measured. The number of incidents for the 10 male patents and the original 10 female patients can be directly compared pre and post reconfiguration. Reasons for the increase and service development and risk management issues will be discussed in the poster presentation. The extent of personality services in the East Midlands region of England Dr Amanda Tetley a *, Miss Mary Jinks a Nick Huband a b , Professor Kevin Howells a b a , Professor Conor Duggan c a , Professor Mary McMurran , Dr Steve Geelan , Dr John Milton* , & Dr Adarsh Kaul a , Dr d Institute of Mental Health, University of Nottingham, Nottinghamshire, UK Arnold Lodge, Nottinghamshire Healthcare NHS Trust, Nottinghamshire, UK c Rampton Hospital, Nottinghamshire Healthcare NHS Trust, Nottinghamshire, UK d Wells Road Centre, Nottinghamshire Healthcare NHS Trust, Nottinghamshire, UK *denotes presenting author Personality disorder is a disabling and complex condition that affects a person‘s thoughts, feelings, perceptions, and relationships with others, often causing subjective distress. It has been estimated that 4.4% of the general population (Coid et al., 2006) and 65% of prisoners (Fazel & Danesh, 2002) attract this diagnosis. In 2003, the National Institute for Mental Health in England (NIMHE) highlighted the absence of service provision for people with personality disorder in both forensic and non-forensic services and subsequently emphasised the need for greater service provision for this client group. Although some dedicated forensic and non-forensic personality disorder services have since been piloted by the Department of Health since 2003, it unclear what other dedicated services for people with personality disorder have been developed. Accordingly, this poster reports on investigation of the level of dedicated forensic and non-forensic service provision for this client group in one region of England, namely Nottinghamshire, Lincolnshire, and Derbyshire. Searches were conducted to identify all dedicated NHS and independent services, and senior clinicians within each identified service were asked to complete a survey about their facility. Our findings revealed that dedicated service capacity within this region appears to be severely inadequate to meet the needs of offenders and non-offenders with personality disorder. They also revealed disparity in the level of community service provision across the three counties, with the provision in some counties more limited than in others. Based on these findings, it is concluded that there is insufficient dedicated service provision in this region for those with personality disorder and that variation in service provision across the region is likely to produce geographical inequalities in the receipt of treatment. It is likely that these same observations are true throughout England. Characteristics of patients in three low secure forensic wards in the country Dr Pratish Thakkar, Consultant Forensic Psychiatrist (Tees Esk and Wear Valley NHS Foundation Trust) Dr Ipsita Ray Speciality Doctor (Tees Esk and Wear Valley NHS Foundation Trust) Dr Ramneesh Puri, ST-6 Forensic Psychiatry, (Birmingham and Solihull Mental Health NHS Foundation Trust) Dr Deepak Tokas Speciality Doctor-(East London NHS Foundation Trust) Introduction Low Secure Psychiatric Care, along with regional and high secure services has been a developing speciality in the UK over the past 25 years However, little is known of the provision, roles and patients cared for by such units. In the literature we found survey looking at provision in the non forensic low secure ward and PICU. The forensic Low Secure ward is a developing area with quite diverse populations. In this study we have analysed data from three low secure forensic wards across the country (North, Midlands and London). Methods The study is a cross sectional study designed to collect data on the same day across the 3 units. We designed a questionnaire looking at the following areas: age, diagnosis, ethnicity, MHA section, source of admission, Index offence (If any), medication (if of high dose antipsychotics) forensic history and history of substance misuse. The data was anonymised as the data was collected by the three co-authors and analysed by the presenting author. Results We are planning to compare the findings from the three units and look if there are any statistical differences. We still await the final data from one of the units and this and other exact figures will be presented at the conference. The following are the major findings: The most common diagnosis of the patient was Schizophrenia or schizotypal illness. Majority of the patients were detained under the Part 3(Forensic Section) of the mental health act and were under restriction from the ministry of justice. Having a forensic history was common in the patients and violence against a person was the most common offence. Majority of the patients had a need to address their substance misuse problems but were not high dose antipsychotic treatment. The source of admission was roughly equal from Medium secure unit, other low secure. Some were admitted directly from prison and others were PICU Due to the location of the three units the ethnicity varied greatly between them. Conclusions We feel that low secure forensic wards are a diverse population. More research in needed to gain knowledge about the patients being treated in them. A quality network similar to that for Medium secure unit needs to be developed for low secure forensic wards. ] Impact of Smoking Cessation on Rates of Adverse Incidents Author: Dr. Deepu Thomas, MRCPsych, StR 5, Forensic Psychiatry Co-authors: Dr. Lakshmanan Ramachandran, MRCPsych, StR 6, Forensic Psychiatry Dr. Jennie McCarthy, MRCPsych, Consultant Forensic Psychiatrist (All employed by Mersey Care NHS Trust, Liverpool) Introduction: Smoking affects pharmacokinetics of psychotropic medications. This is significant in treating mentally ill offenders who often present with severe and/or treatment resistant psychosis, and frequently with poor compliance with treatment. Smoking cessation can potentially reduce the therapeutic dose needed; improve response to treatment, and consequently, compliance as well as general wellbeing. Aims: Identify impact of smoking cessation, implemented on 03 July 2008, on adverse incidents for adult male and female offenders in an NHS medium secure unit in Northwest of England. Objectives: Identification of changes in frequency of different categories of adverse incidents before and after implementation. Methods The unit‘s medical records for the period July 2007 to July 2009 served as the sampling frame while providing the demographic data. The sample (N=43) included all those who were an inpatient in the unit on 3 July 2008. DATIX, the electronic adverse incident database, provided the adverse incident data. To explore clustering of incidents surrounding implementation, rates of different categories of incident were examined (i) 6 months before and 6 months after the implementation and (ii) 1 year before and 1 year after the implementation. Results Of the 43 patients 39 smoked cigarettes. Following cessation of smoking, number of incidents under the category of ‗Aggressive Behaviour‘ decreased from 132 to 52; number of ‗Self Harm‘ incidents decreased from 43 to 10; ‗Alcohol Use‘ on the ward decreased from seven to three incidents; ‗Fire alarm‘ related incidents increased from two to seven and ‗Sexual Assault‘ incidents decreased from seven to two. Eight incidents directly related to smoking and six incidents of trading in contraband following the smoking cessation implementation were recorded in the year following the smoking cessation whereas none were recorded before. Limitation: Inconsistencies amongst professionals reporting incidents (for e.g. similar incidents categorised differently etc) affected the accuracy of the adverse incident data. Conclusions: In our survey there were clearly issues related to accuracy of incident reporting process. There were, however, some notable changes in frequencies of incidents that involved harm to others. These changes will need further systematic exploration before these are attributed to smoking cessation. Antipsychotic Use in a Cohort of Patients Admitted to Ashworth Hospital between June 2004 and May 2005 Dr P F Xavier (Specialty Registrar in Forensic Psychiatry), Dr E Silva (Consultant Forensic Psychiatrist) Ashworth Hospital, Parkbourn, Maghull, Liverpool L31 1HW email:[email protected] INTRODUCTION: Literature on the type of antipsychotic medications that are prescribed in High Secure Forensic Psychiatry Hospitals is limited. In this service evaluation, we set out to identify antipsychotics that were being prescribed for patients in Ashworth High Secure Forensic Psychiatric Hospital in Liverpool, who had a diagnosis of either Schizophrenia or Schizoaffective disorder. The evaluation was part of an attempt to understand prescribing practices in this cohort of patients. AIM: To study practices related to the prescription of anti-psychotic medications and to evaluate duration of treatment as a quasi outcome measure of effectiveness in patients with Schizophrenia or Schizoaffective disorder admitted to Ashworth Hospital between June 2004 and May 2005. METHODOLOGY: A list of patients admitted in the given period was obtained. Patients with a diagnosis of either Schizophrenia or Schizoaffective disorder were included in the study. Information on basic demographic details, diagnoses and antipsychotic medications prescribed was obtained from PACIS (electronic hospital records) and this was collated for the six year period from June 2004 till May 2010 and analysed. The antipsychotic medications were categorised based on nature i.e. typical or atypical, and route of administration i.e. oral or intramuscular depot. FINDINGS: A total of 33 patients were admitted in that year. Of these patients only 27 fulfilled the study criteria based on diagnosis. 13 of these patients were transferred out in the next 6 years and this included 2 deaths. The average duration of stay in Ashworth Hospital for this cohort of patients was 236 weeks (4.5 years). Clozapine was the antipsychotic that was prescribed for the longest duration followed by Olanzapine. At the time of transfer, no patient was on a typical oral antipsychotic. An equal number of patients were on Olanzapine or Clozapine. One patient was on Flupentixol depot and two patients were not on any antipsychotic medications. SUMMARY: The findings of this service evaluation give an insight into the prescribing practices of antipsychotic medications in Asworth High Secure Forensic Psychiatric hospital. Clozapine and Olanzapine were unsurprisingly found to be the two longest prescribed antipsychotics in this cohort of patients and the antipsychotics that patients were most likely to be prescribed when they are transferred out of Ashworth Hospital. Volumetric structural abnormalities of the Amygdala and Hippocampus in men with violent antisocial personality disorder and schizophrenia Dr Elizabeth Zachariah a, Prof Pamela Taylor b, Prof Veena Kumari C a Department of Forensic & Neurodevelopmental Science, Institute of Psychiatry, Kings College London, London, UK b c Department of Psychological Medicine, School of Medicine, Cardiff University, Cardiff, UK Department of Psychology, Institute of Psychiatry, King’s College London, London, UK Introduction Antisocial personality disorder and schizophrenia are both associated with an increased risk of violence. Previous studies have reported prefrontal-temporo-limbic abnormalities in association with violence in mental illness. Studies exploring the temporolimbic structures have found structural abnormalities of the amygdala and hippocampus in personality disorder, psychopathy and schizophrenia. Aim This study compared whole brain, amygdala and hippocampus volumes using structural magnetic resonance imaging in four groups of men. Methods Group 1 had men with a diagnosis of personality disorder (N=30), Group 2 had men with schizophrenia/delusional disorder (N=32), Group 3 had patients with a dual diagnosis of personality disorder and schizophrenia (30) and Group 4 consisted of men without a history of violence or mental illness (n=21). All subjects within the patient group had committed homicide/near-fatal assault. T1-weighted scans were acquired using a 1-Tesla MRI scanner. Raters blind to the subject status measured whole brain, amygdala and hippocampus volumes. Socio-demographic data and details of clinical history were recorded for all participants. Clinical assessments consisted of National Adult Reading Test, Wechsler Adult Intelligence Scale, Comprehensive Psychiatric Rating Scale, and the Positive and Negative Syndrome Scale. Assessment of violence was measured using ratings developed from the criminal profile of Gunn and Robertson. Differences in whole brain volume were analyzed using one-way analysis of variance (ANOVA) with groups as a between-subjects factor. Differences in amygdala and hippocampus volumes were analysed using two-way 2 x 4 analysis of co-variance (ANOVA) with hemisphere (left and right) as a within-subjects factor, groups as a between-subjects factor and whole brain volume as a covariate. One-way analysis of variance (ANOVA) was used to examine differences in age and clinical variables. Chi-square analyses were used to examine group differences in categorical variables for ethnicity, socio-economic status and level of education. Results The findings showed that the different groups have differential as well as shared abnormalities in relation to violence. Compared to normal controls both the personality disorder group and the psychotic group had reduced amygdalar volumes. There was only a trend for smaller amygdala in the dual diagnosis group relative to the control group. The psychotic group had reduced hippocampal volumes in addition to amygdalar abnormality. The dual diagnosis group had reduced whole brain volume in comparison to normal controls and the personality disorder group but did not differ from the psychotic group. The results suggest that volumetric reductions of the whole brain, amygdala and hippocampus are related to specific diagnostic group. Case report & literature review: Essential considerations from a patient presenting to forensic service with a Muslim cultural understanding of „Black Magic & Supernatural Possession.‟ and paranoid delusions. Dr Nuruz Zaman, Dr Rekha Soni & Dr Owen Samuel Robin Pinto Unit, South Essex Partnership Trust, Calnwood Road, Luton, Bedfordshire LU4 0LU Aim: To review current literature on cultural understanding of black magic and supernatural possession, in evaluating a Muslim patient reporting black magic as causative agent in index offence of possession with intent to harm. Particular focus is given to insight development. Method: Patient case report is presented and a PubMED search was conducted to identify research of significance on this topic. Result: Development of insight in such patients remains particularly intractable. Current research is scarce and in the clinical setting, the determination of religious delusions can be challenging at times. This continues to have implications for psychiatric practice in increasingly multi cultural societies. EXHIBITION/SUPPORT The College would like to thank the following companies for their valuable support of this meeting. Alpha Hospitals Bethlem Archive Art Exhibit Cygnet Health Care John Wiley & Sons Partnerships in Care South London & Maudsley NHS Foundation Trust St Andrew‟s Healthcare St Magnus Hospital The presence of an exhibitor is not an endorsement of its products and exhibitors do not influence the content of the meeting. CONFERENCE ORGANISERS Royal College Faculty of Forensic Psychiatry Conference Executive Organisers Professor Tom Fahy- Co-Programme Organiser Professor Jenny Shaw - Co-Programme Organiser Dr Josanne Holloway – Faculty Finance Officer Royal College Faculty Conference Office Organisers: Michelle Braithwaite – Conference Manager Dela Goka-Conference Administrator Future events calendar-http://www.rcpsych.ac.uk/events/collegediary.aspxCONFEREN Notes ........................................................................................................................... ........................................................................................................................... ........................................................................................................................... ........................................................................................................................... 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Back Cover Images: ‗Tree‘ By kind permission of artist John McKie ‗Shapes‘ By kind permission of artist Leon ‗Totem‘ By kind permission of artist Roy Images from the Bethlem Gallery (http://www.bethlemgallery.com)
