The current recommended treatment for patients with recurrent episodes of schizophrenia and related conditions is antipsychotic medication. However, many antipsychotic users remain functionally impaired and experience serious physical and mental side effects. This study aims to assess the cost-effectiveness of a gradual antipsychotic reduction and discontinuation strategy compared with maintenance treatment over 24 months from mental health services, health and social care, and societal perspectives.

Nineteen mental health trusts recruited patients to the Research into Antipsychotic Discontinuation and Reduction (RADAR) randomized controlled trial. Quality-adjusted life-years were calculated from patient-reported EQ-5D-5L, with years of full capability calculated from the patient-reported ICECAP-A. Mental health services use and medication was collected from medical records. Other resource use and productivity loss was collected using self-completed questionnaires. Costs were calculated from published sources.

A total of 253 participants were randomized: 126 assigned to antipsychotic dose reduction and 127 to maintenance. There were no significant differences between arms in total costs for any perspectives. There were no significant difference in quality-adjusted life-years (-0.035; 95% CI: -0.123 to 0.052), whereas years of full capability were significantly lower in the reduction arm compared with the maintenance arm (baseline-adjusted difference: -0.103; 95% CI: -0.192 to -0.014). The reduction strategy was dominated by maintenance for all analyses and was not likely to be cost-effective.

It is unlikely that gradual antipsychotic reduction and discontinuation strategy is cost-effective compared with maintenance over 2-years for patients with schizophrenia and other recurrent psychotic disorders who are on long-term antipsychotics.

Previous research has suggested that the core features of autism spectrum disorders (ASD) may contribute to offending behaviours and increased vulnerability within the Criminal Justice System. To date, there is a paucity of evidence assessing the effectiveness of interventions for offending behaviour in adults with ASD but without co-occurring intellectual disability (ID) across a broad range of forensic settings. The lack of robust evidence is concerning, as limited effectiveness may contribute to an increased likelihood of prolonged incarceration, particularly in the most restrictive settings. A PRISMA systematic review was conducted with a narrative synthesis to: (a) evaluate the evidence of the effectiveness of interventions aimed at reducing recidivism, (b) assess whether the core features of ASD impact the effectiveness of these interventions, and (c) identify additional factors that may affect the effectiveness of interventions within this population. Seven studies involving ten male participants were identified. The findings suggest that interventions for offending behaviours in adults with ASD without intellectual disability (ID) are largely inadequate, and that core ASD features need to be considered. Additionally, a complex interplay of risk factors potentially impacting intervention effectiveness was suggested. Limitations include heterogeneity across intervention types, measures of effectiveness, and what constitutes effectiveness. Despite the limited number of studies and data quality, the review aligns with a growing body of literature highlighting vulnerability and a need for evidence-based interventions for people with ASD. The review also discusses the broader implications of ineffective interventions.

WHAT IS KNOWN ON THE SUBJECT?: International reviews have looked at therapy outcomes for patients on mental health wards, showing it is associated with reduced emotional distress and readmission. Reviews have not looked at which specific treatments are most effective. No review has been done in England and Wales for patients detained specifically under the Mental Health Act.

The paper gives an overview of the limited evidence in England and Wales. The paper shows which therapies have been measured. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Larger studies are needed across all types of patient wards in England and Wales with random allocation to types of therapy and longer-term follow-up. More studies are needed where researchers are not aware of the therapy being delivered. More studies need to use a mixture of patient and clinician outcome measures. Outcomes should also measure incident, readmission and reoffending rates. More evidence is needed from patients who are female, non-white and who are diagnosed with depression and anxiety.

INTRODUCTION: The efficacy of psychological interventions delivered under the Mental Health Act (1983) (MHA) in England and Wales is unclear. While meta-analyses have reviewed acute and forensic psychological interventions in wider geographical areas, there has been no review specifically in the unique MHA context.

A systematic review was conducted of psychological outcomes for inpatients detained under the MHA in England and Wales.

Diagnoses and type of psychological intervention were not restricted, provided a psychological outcome measure was used. Studies were identified through APA PsychInfo, MEDLINE, CINAHL and Academic Search using a combination of key terms. Data extraction included effect direction, statistical significance, intervention type, format and duration, study size, inpatient setting, control group and study quality.

High-quality evidence was sparse. Some improvements were found in overall well-being, self-esteem, social functioning, problem-solving, substance use, anger, offending attitudes, fire-setting, violence, anxiety, depression, personality disorder and psychosis. However, the overall evidence base is lacking.

Larger-scale randomized controlled trials are needed across secure, acute and learning disability inpatient settings in England and Wales with longer term follow-up, blind assessors and both self-report and clinician-rated measures, as well as incident, readmission and reoffending rates. Greater representation is needed of females, non-white groups and affective disorders.

The efficacy of psychological interventions for inpatients detained under the MHA in England and Wales remains unclear. Clinicians are encouraged to use relevant outcome measures in relation to treatment goals, to monitor the efficacy of interventions being offered to this client group.

This paper highlights the current body of evidence for psychological interventions in inpatient settings within England and Wales, which is an environment in which mental health nursing plays an important role in patients' recovery. This evidence is also particularly important as there is a shift in clinical practice to training nursing staff to deliver some of the low-intensity psychological interventions, such as behavioural activation, solution-focussed therapy and motivational interviewing.

Forensic mental health services provide care to people in secure psychiatric hospitals and via specialised community teams. Such services are typically low volume and high cost, often highly restrictive and average duration of inpatient care prior to discharge is long. Measuring outcomes of care is important to safeguard patients and the public, monitor progress, inform treatment plans and assist in service evaluation and planning. We describe the development in England of a new outcome measure for forensic mental health services. Patient interviews and multistakeholder focus groups were held to elicit key concepts. Thematic analysis was used to develop an outcomes framework. Fifteen patients participated in the interviews and 48 stakeholders in the focus groups. Six domains were identified in thematic analysis: 'about me, my quality of life, my health, my safety and risk, my life skills and my progress'. Sixty-two stakeholders participated in the first round of the Delphi process, and 49 completed round two. Eight of the top fifteen outcomes were shared between patients/carers and professionals. Based on these results, a new outcome measure, the FORensic oUtcome Measure (FORUM), was developed including both a patient reported and clinician reported measure. Further assessment of the FORUM's use to track patients' progress over time, and facilitate shared decision-making and care planning, is required.

Although risk assessment tools have been widely used to inform sentencing decisions, there is uncertainty about the extent and quality of evidence of their predictive performance when validated in new samples. Following PRISMA guidelines, we conducted a systematic review of validation studies of 11 commonly used risk assessment tools for sentencing. We identified 36 studies with 597,665 participants, among which were 27 independent validation studies with 177,711 individuals. Overall, the predictive performance of the included risk assessment tools was mixed, and ranged from poor to moderate. Tool performance was typically overestimated in studies with smaller sample sizes or studies in which tool developers were co-authors. Most studies only reported area under the curve (AUC), which ranged from 0.57 to 0.75 in independent studies with more than 500 participants. The majority did not report key performance measures, such as calibration and rates of false positives and negatives. In addition, most validation studies had a high risk of bias, partly due to inappropriate analytical approach used. We conclude that the research priority is for future investigations to address the key methodological shortcomings identified in this review, and policy makers should enable this research. More sufficiently powered independent validation studies are necessary.

Treatment for offenders with mental disorders is a key concern in public mental health. Provision of adequate psychiatric treatment is important for the offender and their community. An approach used in Japan to address this issue is administrative involuntary hospitalization. Under this scheme, a person at risk for harming themselves or others because of a mental disorder can be involuntarily hospitalized in a designated psychiatric hospital. However, this scheme does not include tracking of these patients after discharge. Although some data for administrative involuntary hospitalizations are available, it remains unclear what happens to these patients after discharge.

To evaluate follow-up of patients under administrative involuntary hospitalization after discharge and obtain data for later comparisons with outcomes.

We used a retrospective design and conducted a national survey of administrative involuntary hospitalizations. Questionnaires were distributed to 939 facilities across Japan. The questionnaire collected data for selected involuntary hospitalization cases in the hospital on June 30, 2010 (census date), and the prognoses of each patient on a specified date in 2011 and 2012. We also asked about the treatment provided to each patient. We stratified patients by prognosis (good or poor), and used logistic regression analysis to examine the relationship between treatment and prognosis.

We received completed questionnaires from 292 facilities (response rate 31.1%); 105 facilities had no relevant patients. Our analysis included data for 394 patients with valid data. Official statistics indicated 1503 patients were under administrative involuntary hospitalization as at June 30, 2012, meaning the capture rate was 27.2%. Approximately a fourth (104/394) at 1 year, and a third (137/294) at 2 years after the census had unknown prognosis. Treatment content included multi-disciplinary team meetings (78.2% of patients), counseling by public workers (59.9%), and discussion with external specialists (32.5%). Overall, 116 patients were categorized as having a good prognosis at 1 year, and 168 had a poor prognosis. At the 2-year point, 102 patients had a good prognosis and 150 had a poor prognosis. "Discussion with external specialists" was positively associated with a good prognosis at both 1 year (P = 0.016) and 2 years (P = 0.036).

We found that facilities in Japan currently have limited ability to track the prognoses of patients who were hospitalized involuntarily. Discussion with external specialists is associated with a good prognosis.

Interpersonal violence is a leading cause of morbidity and mortality. The strength and population effect of modifiable risk factors for interpersonal violence, and the quality of the research evidence is not known.AimsWe aimed to examine the strength and population effect of modifiable risk factors for interpersonal violence, and the quality and reproducibility of the research evidence.

We conducted an umbrella review of systematic reviews and meta-analyses of risk factors for interpersonal violence. A systematic search was conducted to identify systematic reviews and meta-analyses in general population samples. Effect sizes were extracted, converted into odds ratios and synthesised, and population attributable risk fractions (PAF) were calculated. Quality analyses were performed, including of small study effects, adjustment for confounders and heterogeneity. Secondary analyses for aggression, intimate partner violence and homicide were conducted, and systematic reviews (without meta-analyses) were summarised.

We identified 22 meta-analyses reporting on risk factors for interpersonal violence. Neuropsychiatric disorders were among the strongest in relative and absolute terms. The neuropsychiatric risk factor that had the largest effect at a population level were substance use disorders, with a PAF of 14.8% (95% CI 9.0-21.6%), and the most important historical factor was witnessing or being a victim of violence in childhood (PAF = 12.2%, 95% CI 6.5-17.4%). There was evidence of small study effects and large heterogeneity.

National strategies for the prevention of interpersonal violence may need to review policies concerning the identification and treatment of modifiable risk factors.Declarations of interestJ.R.G. is an NIHR Senior Investigator. The views expressed within this article are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Health services are increasingly required to measure outcomes after treatment, which can be reported to the funding body and may be scrutinised by the public. Extensive high-quality measurements are time consuming. Routinely collected clinical data might, if anonymised, provide good enough evidence of useful change consequent on service received.

Do the Health of the Nation Scale and the 20-item Historical, Clinical, Risk structured professional judgement tool scores provide evidence of clinical and risk change among low security hospital patients at 6 and 12 months after admission?

One hundred and eight men were either resident on the unit on 1 January 2011 or new admissions to the census date of 31 May 2013. Their routinely collected data were added to an outcome register following each patient's Care Programme Approach clinical review meeting and analysed using repeated measures t-tests with Bonferroni corrections.

Most of the men, mean age 34.3 years, were single (93%), White British (71%) and with a primary diagnosis of schizophrenia (62%). There were significant reductions in the 11-item Health of the Nation Scale (excluding the community living condition scale) scores between baseline and 6 months and between 6 and 12 months, but no change on its additional 7-item secure subscale. Individual effect sizes indicated that 39% of the men had better social function, although 18% had deteriorated at 6 months. There was little overall change in the 20-item Historical, Clinical, Risk; individual effect sizes indicated that 11 men (15%) were rated as being at lower risk level and 10 (14%) at higher after 6 months in the study.

Standard clinical measures are promising as indicators of change in low security hospital patients. Risk ratings may be conservative, but at this stage of a secure hospital admission, higher scores may be as likely to indicate progress in identifying and quantifying risks as apparent increase in risk. Copyright © 2017 John Wiley & Sons, Ltd.

Routine outcome measures are increasingly being mandated across mental health services in Australia and overseas. This requirement includes forensic mental health services, but their utility in such specialist services and the inter-relationships between the measures remain unclear. This study sought to characterise the risks, needs and stages of recovery of an entire cohort of forensic patients in one jurisdiction in Australia.

Local expert groups, comprising of members of the forensic patient treating teams, were formed to gather information about the status and needs of all forensic patients in the State of New South Wales, Australia. The expert groups provided demographic information and completed three assessment tools concerning the risks, needs and stages of recovery of each forensic patient.

The cohort of 327 forensic patients in NSW appears to be typical of forensic mental health service populations internationally when considering factors such as gender, diagnosis, and index offence. A number of important differences across the three structured tools for forensic patients in different levels of secure service provision are presented. The DUNDRUM Quartet demonstrated interesting findings, particularly in terms of the therapeutic security needs, the treatment completion, and the stages of recovery for the forensic patients in the community. The CANFOR highlighted the level of needs across the forensic patient population, whilst the HCR-20 data showed there was no significant difference in the mean clinical and risk management scores between male forensic patients across levels of security.

To the authors' knowledge this is the first study of its kind in New South Wales, Australia. We have demonstrated the utility of using a suite of measures to evaluate the risks, needs, and stages of recovery for an entire cohort of forensic patients. The data set helps inform service planning and development, together with providing various avenues for future research.

Outcomes research in forensic mental health (FMH) has concentrated on reoffending as the principal indicator of success. Defining success in one-dimensional, negative terms can create a distorted view of the diverse objectives of the FMH system. This qualitative study examined the complexity of success from the perspectives of people in the FMH system. Interviews were conducted with 18 forensic service users and 10 forensic service providers. Data were analyzed inductively using thematic analysis to identify predominant themes. The participants conceptualized success as a dynamic process materializing across six different domains in the context of the FMH system: (a) normal life, (b) independent life, (c) compliant life, (d) healthy life, (e) meaningful life, and (f) progressing life. The results indicate that people who provide or use FMH services emphasize a broad range of processes and outcomes, apart from public safety, when they think about success.

This study examined if a macro-, meso-, and micro outcome measurement instrument that constitutes the evaluation stage of a Dutch forensic psychiatric outcome monitor, the Hoeven Outcome Monitor (HOM), can provide a first step towards a more evidence based groundwork in forensic mental health. General, serious, very serious, special, and tbs meriting recidivism during treatment, after treatment, and overall were charted for forensic psychiatric patients discharged from a Dutch forensic psychiatric centre between 1999 and 2008 (N=164). Re-conviction data were obtained from the official Criminal Records System, and the mean follow-up time was 116.2months. First, the results showed that the macro-measurements provide comparative outcome measures to generate insight into the overall effectiveness of forensic psychiatric treatment. Second, the meso-measurements yielded clinically relevant treatment outcome data for all discharged patients to generate a complete view of treatment effectiveness. Finally, the micro-measurements allowed access to detailed patient and treatment effectiveness assessments that provides the empirical foundation to conduct aetiological research into the prediction and control of high-risk behaviour. Thus, an outcome measurement instrument in line with Evidence Based Medicine and best practice guidelines was designed that provides an empirically sound evaluation framework for treatment effectiveness, and an impetus for the development of effective interventions to generate an evidence based groundwork in forensic mental health.

To comply with the need for a more evidence based risk assessment and management in forensic mental health, an outcome monitor is being developed in the Dutch forensic psychiatric centre Van der Hoeven Kliniek in Utrecht, the Hoeven Outcome Monitor (HOM). Conform evidence based medicine (EBM) guidelines, the HOM is subdivided into three consecutive stages, (1) the evaluation stage, (2) the aetiology stage and (3) the implementation stage. In this article an account is provided for the design of the evaluation stage. To account for predicaments in previous research that pertain to a lack of uniformity and disregard of specific context- and patient-related characteristics, a macro-, meso- and micro-treatment evaluation instrument is developed. This instrument provides for the first step to build an evidence base for specific interventions and treatments in forensic psychiatry.

A new legislation concerning forensic mental health was established by the Japanese Government in 2005, the "Act on Medical Care and Treatment for the Persons Who Had Caused Serious Cases under the Condition of Insanity," or the Medical Treatment and Supervision (MTS) Act. Since it was passed, however, there has been broad controversy over Hospitalization for Assessment (HfA), the first stage of the MTS scheme.

Following a comprehensive literature search to assemble a list of candidates, we conducted a Delphi study to establish standard outcome measures for HfA.

Five Delphi rounds were conducted by 19 panelists including medical practitioners and lawyers. A total of 139 items were accepted as outcome measures for HfA based on panel agreement.

The Delphi study established a list of HfA outcome measures for the MTS act, which will contribute to the optimization of the new forensic mental health system in Japan.

Despite evidence of the effectiveness of injectable opioid treatment compared with oral methadone for chronic heroin addiction, the additional cost of injectable treatment is considerable, and cost-effectiveness uncertain.

To compare the cost-effectiveness of supervised injectable heroin and injectable methadone with optimised oral methadone for chronic refractory heroin addiction.

Multisite, open-label, randomised controlled trial. Outcomes were assessed in terms of quality-adjusted life-years (QALYs). Economic perspective included health, social services and criminal justice resources.

Intervention costs over 26 weeks were significantly higher for injectable heroin (mean £8995 v. £4674 injectable methadone and £2596 oral methadone; P<0.0001). Costs overall were highest for oral methadone (mean £15 805 v. £13 410 injectable methadone and £10 945 injectable heroin; P = n.s.) due to higher costs of criminal activity. In cost-effectiveness analysis, oral methadone was dominated by injectable heroin and injectable methadone (more expensive and less effective). At willingness to pay of £30 000 per QALY, there is a higher probability of injectable methadone being more cost-effective (80%) than injectable heroin.

Injectable opioid treatments are more cost-effective than optimised oral methadone for chronic refractory heroin addiction. The choice between supervised injectable heroin and injectable methadone is less clear. There is currently evidence to suggest superior effectiveness of injectable heroin but at a cost that policy makers may find unacceptable. Future research should consider the use of decision analytic techniques to model expected costs and benefits of the treatments over the longer term.

High-risk mentally disordered offenders present a diverse array of clinical characteristics. To contain and effectively treat this heterogeneous population requires a full understanding of the group's clinical profile. This study aimed to identify and validate clusters of clinically coherent profiles within one high-risk mentally disordered population in the UK.

Latent class analysis (a statistical technique to identify clustering of variance from a set of categorical variables) was applied to 174 cases using clinical diagnostic information to identify the most parsimonious model of best fit. Validity analyses were performed.

Three identified classes were a 'delinquent' group (n = 119) characterised by poor educational history, strong criminal careers and high recidivism risk; a 'primary psychopathy' group (n = 38) characterised by good educational profiles and homicide offences and an 'expressive psychopathy' group (n = 17) presenting the lowest risk and characterised by more special educational needs and sexual offences.

Individuals classed as high-risk mentally disordered offenders can be loosely segregated into three discrete subtypes: 'delinquent', 'psychopathic' or 'expressive psychopathic', respectively. These groups represent different levels of risk to society and reflect differing treatment needs.

Much resource (c £500M) has been spent in setting up the programme of treatment for those deemed to be suffering from dangerous and severe personality disorder (DSPD). It has now begun to contract, and it is an appropriate time to evaluate its cost-effectiveness.

The aim of the study was to review all published and known unpublished material, examining the cost, cost function and cost-effectiveness of the DSPD programme since its introduction in 1999.

Narrative review of studies was used.

Four studies, one unpublished, were identified. The costs of treating people in the DSPD programme are considerably higher than those in other parts of the prison service. This could be justified if the gains justified this increased investment, but the evidence suggests that the outcomes in the short term are not good, and the monetary value of reductions in serious offences is very small compared with the extent of the higher costs incurred. There is a dearth of randomised trials that would allow an adequate assessment of cost-effectiveness.

Future plans for expansion or development of DSPD and similar services need to have cost-effectiveness of agreed outcomes assessed as a central element.

Although the increased risk of violent behavior in individuals with schizophrenia is now well-established, there is considerable uncertainty in pharmacological strategies to reduce this risk. In this review, we performed a systematic search of three electronic databases from January 2000 to March 2010 of treatment research on the management of violence in schizophrenia. We identified eight randomized controlled trials. The main findings included the association of nonadherence to antipsychotic medication to violent outcomes, a specific anti-aggressive effect of clozapine and short-term benefits of adjunctive β-blockers. There was little evidence on the efficacy of adjunctive mood stabilizers, depot medication or electroconvulsive therapy. Future research should use validated outcomes, longer follow-up periods and investigate patients with comorbid substance misuse.