###### Created: 2024-07-12 11:01 ###### Author: John Tully et al. ###### Areas & Topics: #medicine #psychiatry ###### Note Type: #literature ###### Connected to: [[]] ###### Source: https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(24)00164-0/abstract#:~:text=We%20conclude%20that%20insufficient%20investment,societal%2C%20and%20public%20health%20levels. - This paper mentions that forensic mental health is low-volume, high cost service and uses lots of novel therapies and techniques (e.g. segregation, long-term detainment). - These techniques and therapies however, don't have much of an evidence base. - Additionally, 1/5th of all the UK mental health budget is spent on forensics, serving 8000 patients. - This high amount of cost puts pressure for the service to be effective and supported by strong evidence where possible. - Forensic psychiatry is also often criticised for lacking consistency in standards. - This is, in part, attributed to a lack of forensic psychiatry in lower-income countries and the lack of well-trained researchers on the subject. - With all this in mind, the main goal of the paper is to address gaps in this evidence base and offer potential changes and solutions to combat this lack of evidence. ### Improving Evidence Base **Psychotherapy** - Psychotherapy and psychosocial interventions aren't well researched and only show small effects in prison and forensic psychiatric populations when compared with other treatments. - They also don't typically monitor for unwanted effects, which have been shown to occur in up to 26% of patients according to some studies. - Essentially, good RCTs are needed to evaluate harms and provide better evidence for the therapies. **Pharmacotherapy** - Pharmacotherapy RCTs haven't shown both symptom resolution and reduced risk of violence in forensic settings typically. - There are lots of cofounders for pharmacotherapy effects, and high amounts of pharmacotherapy and polypharmacy have been shown to cause short and long-term adverse effects. - Pharmaco-epidemiological studies have shown that antipsychotics in a general population can reduce both symptoms and risk of violence. - In forensics however, these studies have shown that antipsychotics and mood stabilisers used together don't reduce incidences of violent crime, but anti-psychotics and anti-craving medication used together might reduce symptoms and risk of violence in patients with dual diagnoses. **Risk Assessment and Management** - The paper states that good tools are needed to assess risk and advise management. - The Historical Clinical Risk-Management 20 (HCR-20) is a good and widely used tool to assess risk, but using it requires lots of man-hours and training, and its usefulness for specific patient groups isn't well studied. - These type of tools are best used when trying to guide individual management, but some practitioners try and use them to predict the future risk of patient's which can be problematic. - In summary, risk prediction and assessment tools need more research, including base population and demographic information and how management affects patient outcomes following their use. **Restrictive Practices** - So far, there is not much evidence for the use of restrictive practices and their outcomes. - According to a 2012 Cochrane Review, there were no controlled studies looking at the use of restraint for those with serious mental illness. - Some qualitative studies have shown serious adverse effects from use of restraint in patients with serious mental health issues. - Part of the reason there are no controlled studies on this topic are because RCTs on this subject are difficult to produce, due to incidents and restrictive practice use being hard to measure or predict. - Additionally, risk prediction and restraint necessity is very subjective which complicates things further. - Electronic monitoring using GPS is starting to be shown as helping to increase patients access to leave and can be cost-neutral, but this needs to be looked into further. - In essence, restrictive practices need much more research. ### Developing contemporary research approaches **Forensic neuroscience** - Genetic studies and neuroimaging techniques are rapidly developing, but are meeting resistance from forensic areas in their use. - This is in part due to the difficulties in getting patients to agree to be studied and what the paper terms as 'therapeutic nihilism' from forensic clinicians regarding conditions such as antisocial personality disorder and psychopathy - This basically means that forensics are currently reluctant to give patients for neuroscience studies which limits the area further. - The paper suggests more needs to be done to remove stigma around neuroscience for both patients and practitioners and better inform both groups about potential long-term impacts and benefits of the field. - This is further supported by qualitative studies showing men with antisocial personality disorder being interested in uncovering precipitants of their behavioural patterns, but simultaneously having anxiety about involvement in research and the practicalities of this. **Big Data Approaches** - Other countries have seen quite a lot of success using nationally-linked data gathering techniques to collect all facets of patients data consistently across all services (e.g. prison, community, healthcare etc.). - At the moment, there is no UK-wide forensic resources in existence. - Having nationally linked data shared between healthcare and forensic services could allow for the creation of large data sets to study and produce population wide research. - Currently, some companies are making research datasets from administrative sources, but national criminal justice information needs to be included to increase its usefuleness. **Considering equity and patient perspectives** - The paper mentions that minorities are more likely to be detained involuntarily and black people are currently very overrepresented in locked wards, secure units and psych hospitals. - There needs to be more research to see why minority and Black groups experience this. - The paper also suggests the need for patient involvement in healthcare decisions and research, but there isn't much evidence to say how involved forensic patients are in this way currently. ### Developing the forensic clinical-academic workforce **Developing the clinical-academic pathway** - Clinical academic psychiatry has been declining since 2007. - There is also currently a deficit in non-medical mental health clinical academics compared to other areas of medicine. - Doctors tend to be introduced late to forensics and related research. making it harder to get into as clinicians are later in their careers when starting. - The paper suggests that research and access to mentors etc. needs to be supported at all levels to help combat this decline. **Building Collaborative Networks** - Forensics is segmented in nature currently, so research ends up being segmented and sub-specialised as well. - This means that large-scale studies which link multiple areas of forensics tend to be limited. - There is also no current strategy for identifying over-arching gaps in forensic research either and no UK-wide network for forensic-mental health academics. - The paper basically suggests that forensic areas should be better linked and a UK-wide network should be made. **Forensic Mental Health Education** - The paper suggests that increasing undergraduate student exposure to forensics and making better training pathways for clinical educators in forensics would be ideal.