The Forensic Research Nottingham (FRN) group was established early in 2021, with a view to further developing forensic research both in Nottinghamshire Healthcare NHS Foundation Trust and at the University of Nottingham. It provides a collaborative forum to bring together all those linked to either of the two organisations and interested or active in forensic research.

We were especially keen to develop cross-disciplinary research and were very pleased to have amongst our early membership researchers from IMH Centres of Excellence. In 2022, the forensic service recruited a second Clinical Associate Professor in Forensic Psychiatry, further supporting a long-term vision for forensic research in Nottingham. Another group goal has been to continue to build collaborative links across the UK. Joint projects and co-applications over the last year have seen us link with colleagues across many different institutions. Below, we highlight progress related to two of our core research interests (forensic neuroscience and violence risk assessment), other output by the group in the 18 months, and future directions.

Forensic Neuroscience

One especially neglected area in forensic mental health research is the biological contribution to the common disorders and dysfunctional behaviours seen in our patient population. Large scale genetic research has suggested a strong biological contribution to antisocial behaviour and violence, however studies examining the precise brain mechanisms by which this occurs are relatively lacking. Two papers led by John Tully, both published in Nature Mental Health [1, 2], have offered novel insights into the neurobiology of two important disorders in forensic settings- antisocial personality disorder (ASPD) and psychopathy.

Firstly, a multi-centre collaborative systematic review and meta-analysis of structural brain imaging in the disorder and its developmental precursors (Disruptive Behaviour Disorders) demonstrated for the first time the role of variability in brain structure in the condition [1]. Variability in brain structure has been increasingly identified as an important contributor to a number of psychiatric disorders, including schizophrenia and autism, but until now had not been investigated in antisocial populations. This study showed that the amount of variation in the structure of overall grey matter was significantly greater in antisocial groups, compared to the healthy controls. This suggests that this variability, rather than just differences in brain size or shape, may be an important additional factor in distinguishing antisocial groups, and perhaps explain some of the clinical variation we see within those groups. This work drew on the skillsets of research groups in Oxford, London, and Copenhagen, demonstrating the value of developing collaborative networks. Notably, it also involved a junior doctor, Brooke Gerrie, who became involved as part of the Nottingham-led PsychStart scheme which provides mentorship for medical students interested in psychiatry.

A second study, based on John’s PhD work at Kings College London, yielded the first evidence of pharmacological effects on emotion processing in ASPD +/- psychopathy sample [2]. Using a randomised, double-blinded design with functional MRI to measure neural effects of intranasal oxytocin, the study found that those with psychopathy demonstrated an abnormal response to viewing fearful faces with placebo, but a ‘normalising’ response to oxytocin. This provides a robust basis to support further pharmacological research in the condition, and has potential implications for treatment approaches, including combined psychological and pharmacological strategies. For this work, John won the Royal College of Psychiatrists Forensic Faculty New Research award in 2023.

Violence in mental illness: epidemiology and risk assessment

The nature of the association between mental illness and violence perpetration is an important question in psychiatry, with much wider relevance for society, law and public health policy. Continuing his interest in epidemiology and evidence-synthesis in this area, in July Daniel Whiting presented at the Royal College of Psychiatrists’ International Congress in Liverpool on a meta-analysis he led on the association between schizophrenia spectrum disorders and violence. This work was published in JAMA Psychiatry in 2022 [3]. The increased risk compared with control groups was consistent despite differences between studies, such as their design and outcome definition. It highlighted the effects of comorbid substance misuse, and the context of absolute risks (fewer than 1 in 4 men and 1 in 20 women with schizophrenia perpetrate violence). This context is important for how the link is communicated, and its relation to stigma, which is one subject of an upcoming follow-up letter in World Psychiatry [4].   

A core issue arising from this work is how best to approach the assessment and management of this risk in clinical populations. One clinical setting in which this is particularly relevant is services for first episode psychosis. Daniel recently published in BMJ Mental Health some of the work from his PhD at the University of Oxford that tested a simple, scalable prediction model approach to this (with the “OxMIV” tool) [5].  This study provided several important insights, including i) a robust estimate of the prevalence of violence perpetration in this population, using combined healthcare and police data in a large clinical cohort of 1,145 people, ii) external validation of a prediction tool using real-world, routinely available clinical data, and iii) for the first time, a direct comparison of the accuracy of the prediction tool approach with current practice, which is unstructured clinical assessment. The importance of examining different metrics of accuracy when evaluating a clinical risk tool is further considered in a meta-analysis of risk assessment tools in forensic settings, which Daniel contributed to, and will shortly be published in The Lancet Psychiatry [6].    

Determining how clinical risk assessment can lead to improved outcomes (i.e. violence reduction) is an important future direction. Daniel has also been involved in another related recent review,  exploring evidence for violence prevention interventions in the general population [7]. The approach to risk assessment within hospital settings, including how this can be made more collaborative within the secure mental health pathway, has been the topic of several recent FRN grant submissions in collaboration with colleagues in Oxford, Manchester, London, and at Rethink Mental Illness. 

Systematic Review of Prison Transfers to Hospital

Another important area for forensic research is the outcomes of our prison population. One key consideration is the time it takes to transfer mentally unwell prisoners to psychiatry hospital for treatment. This was identified as major area for improvement by the 2009 report on mental health in prisoners and those with learning disabilities, led by Lord Bradley. Work led by Andrew Forrester around this time showed that despite an established 14-day target for transfer to hospital of mentally unwell prisoners, this was often not met, with UK average being over 50 days. Our group, led by Christian Sales and John Tully, collaborated with Andrew Forrester, now Professor of Forensic Psychiatry at Cardiff University, to conduct an updated review of the evidence [8]. This was novel on two counts: in conducting the first systematic review of the evidence, and in taking, for the first time, an international perspective. In England, four articles were identified, all showing transfer times remain considerably longer than the national targets of 14 days (ranging from 14 days to over 9 months); while one study from Scotland found shorter mean transfer times, but that more patients had been transferred to psychiatric intensive care units (PICU) than to secure forensic hospitals. There were only two studies that investigated prison to hospital transfers for mental disorder from outside the UK, and only one was able to provide transfer time data.

The dispiriting findings of this review highlight failures to resolve transfer delays in England and provide little evidence about the problem elsewhere. A possible confounding factor is that in some countries, all treatment for prisoners’ mental disorders occurs in prison. However, the principle that prisons are not hospitals seems important when people need inpatient care. Prospective, longitudinal cohort studies are urgently needed to map transfer times and outcomes. We hope that our paper will help bring this important issue back into the limelight and provoke discussion amongst policy makers.

Other output of interest from clinical settings

A long-standing strength of forensic research in Nottinghamshire Forensic Services has been the output from the Medium Secure Unit at Arnold Lodge. Previous papers led by Conor Duggan (now Emeritus Professor), Simon Gibbon, and others have added important data to the understanding of progress of patients through UK medium security. A recent paper [9] led by Jodie Westhead, Simon Gibbon and Martin Clarke provided further insights from long-term outcomes from Arnold Lodge. Outcome data were obtained for an impressive cohort of 843 patients discharged prior to the census date June 2013. Key findings included that the risk of death from both natural and unnatural causes was much higher for this cohort than that of the general population; 44% of those discharged were convicted of a further offence during the follow-up period, and 62% were readmitted to psychiatric care. These findings further underline the vulnerabilities and risks posed by this population and the continued need to optimise treatment interventions.

An ageing population has significant implications for forensic services. A series of papers from the ENHANCE project [10-12], which involved our group member Tom Dening, has yielded some important insights into the clinical profiles and needs of older patients in forensic settings. One study from the project [11] revealed that in a sample of forensic hospital and community patients, older patients were prescribed 7.6 medications on average and had average anticholinergic effect on cognition scores of 2.4. Nearly half the sample had diabetes, with an average BMI score of 31.7 (indicating obesity). Possible cognitive impairment was identified in 65% of the sample. The project also revealed that patients’ assessments of their recovery-related quality of life and mental wellbeing were comparable to published UK general population values [12]. Assessments of quality of life were positively correlated with the ability to undertake everyday activities and cognitive performance. Environmental (e.g., physical, structural and facilities), relational (staff, family and friends) and individual (characteristics, feelings, behaviours) factors were identified as enablers and/or obstacles to wellbeing, recovery, progress and quality of life. Building on this work, FRN has now received our first funding, for a further project on older forensic patients, specifically prisoners over the age of 55. The project will be entitled ‘Clinical Profiles and Needs of Older Prisoners (PANOP)’.

Institutional fire-setting is a widespread and serious problem in custodial settings, but has been under-researched. A recent paper led by Phil Willmot [13] described the characteristics and fire-setting histories of 32 patients with histories of institutional fire-setting in a secure psychiatric unit in our trust. The exploratory approach yielded some interesting findings: only six patients had a prior conviction for fire-setting; all institutional fire-setting was carried out alone; fire-setting was significantly more common among patients with a diagnosis of personality disorder than among those with a diagnosis of mental illness. The authors suggest that fire-setting may be one of a very limited repertoire of problem solving strategies, may be inadvertently reinforced in these settings, and that there may be a subgroup of institutional fire-setters with no previous history of fire-setting.

Another interesting area of research to which our group is linked is Music Therapy in forensic settings, through our group member Stella Compton Dickinson. Stella’s work in developing Cognitive analytic music therapy in Nottinghamshire healthcare forensic services is now an established relational model of music therapy across the globe, and is summated in the recent Proceedings of the 17th World Congress of Music Therapy (Special Issue of Music Therapy Today 18(1), available at https://issuu.com/presidentwfmt/docs/mt_today_vol.18_no._1). 

FRN Meetings and Summer Symposia

Our 6-weekly meetings are ongoing, on MS Teams. In the last year or so, we hosted high quality external speakers from University of Edinburgh, Ashworth/Merseyside NHS Trust, Broadmoor, and Kings College London, as well as stimulating presentations from local groups looking to develop new projects. Our first FRN Summer Symposium, on neuroscience in forensic mental health, was held online in July 2021 and allowed for contributors from USA and Canada. However, we felt that to optimise the benefit to local participants, in-person events would be best, and our 2022 event was held on site at University Campus. This included high impact researchers on the psychopharmacology of psychosis, Robert McCutcheon and Siobhan Gee. The 2023 event has been postponed until September due to the consultant strike in July and we are looking forward to welcoming delegates from across the Trust and University, as well as students and clinicians from elsewhere. The theme this year is 'The interface between mental health and justice pathways’ - full details are here. The group is open to suggestions for topics for future symposia. As well as the Summer Symposium, the long-established Trent Study Day has returned in earnest each November since its pandemic-imposed exile, and will this year focus on physical health in forensic settings. 

Next steps

Our group is currently busy at work on a number of further publications and grant applications. We have recruited a PhD student on the highly competitive MRC AIMS programme, co-supervised with Dr Stephane de Brito at University of Birmingham. Clinical and service evaluation projects are underway on topics including a national survey of community forensic service provision, risk assessment and outcomes of community forensic referrals, the impact of Vitamin D monitoring and treatment in prisons, the ethics of electronic monitoring, and work with the Academic Health Science Network to review the evidence for the use of mechanical restraint in secure settings. We are also taking a lead role in helping to establish better links between forensic research groups across the UK, including within the High Secure Research Network, led by our collaborative colleague Dr Jonathan Hafferty at Broadmoor Hospital, and the ENIGMA consortium antisocial behaviour research group. We look forward to updating you again in 12-18 months’ time.

John Tully and Daniel Whiting, September 2023.

References

1.       Tully, J., et al., A systematic review and meta-analysis of brain volume abnormalities in disruptive behaviour disorders, antisocial personality disorder and psychopathy. Nature Mental Health, 2023. 1(3): p. 163-173.

2.       Tully, J., et al., Oxytocin normalizes the implicit processing of fearful faces in psychopathy: a randomized crossover study using fMRI. Nature Mental Health, 2023: p. 1-8.

3.       Whiting, D., et al., Association of Schizophrenia Spectrum Disorders and Violence Perpetration in Adults and Adolescents From 15 Countries: A Systematic Review and Meta-analysis. JAMA Psychiatry, 2022. 79(2): p. 120-132.

4.       Daniel Whiting, G.G., John R Geddes, Kimberlie Dean, Seena Fazel, Violence in schizophrenia: triangulating the evidence on perpetration risk World Psychiatry (in press), 2023.

5.       Whiting, D., et al., Assessing violence risk in first-episode psychosis: external validation, updating and net benefit of a prediction tool (OxMIV). BMJ Mental Health, 2023. 26(1): p. e300634.

6.       Maya G T Ogonah, A.S., Daniel Whiting, Seena Fazel, Violence risk assessment instruments in forensic psychiatric populations: a systematic review and meta-analysis. The Lancet Psychiatry (in press), 2023.

7.       Seena Fazel, M.B., Achim Wolf, Daniel Whiting, Rongqin Yu, Effectiveness of Violence Prevention Interventions: Umbrella Review of Research in the General Population. Trauma, Violence, & Abuse. 0(0): p. 15248380231195880.

8.       Sales, S., Forrester, A., Tully, J., Delays in transferring patients from prisons tosecure psychiatric hospitals: An internationalsystematic review. Criminal Behaviour and Mental Health, 2023.

9.       Westhead, J., et al., Long-term outcomes after discharge from medium secure care: still a cause for concern? The Journal of Forensic Psychiatry & Psychology, 2023. 34(2): p. 166-178.

10.      Walker, K., et al., Staff perspectives on barriers to and facilitators of quality of life, health, wellbeing, recovery and reduced risk for older forensic mental-health patients: A qualitative interview study. Journal of Health Services Research & Policy, 2022. 27(4): p. 287-300.

11.      Tomlin, J., et al., Older forensic mental healthcare patients in England: demographics, physical health, mental wellbeing, cognitive ability and quality of life [version 2; peer review: 2 approved]. NIHR open research, 2022. 2: p. 9.

12.      Walker, K., et al., Quality of life, wellbeing, recovery, and progress for older forensic mental health patients: a qualitative investigation based on the perspectives of patients and staff. International Journal of Qualitative Studies on Health and Well-being, 2023. 18(1): p. 2202978.

13.      Willmot, P. and A. Mason, Institutional firesetting in a forensic inpatient population. The Journal of Forensic Psychiatry & Psychology, 2023: p. 1-15.