The novel corona virus disease COVID-19 was first diagnosed in humans in Wuhan, China in December 2019. Since then it had become a global pandemic. Such a pandemic leads to short-and long-term mental health burden for healthcare workers. Recent surveys suggest that rates of psychological stress, depression, anxiety, and insomnia and will be high for this group. Numerous organizations have since released guidance on how both healthcare workers and the general public can manage the mental health burden. However, these recommendations focus on specific healthcare workers (e.g., nurses or psychologists), are often not evidence-based, and typically do not situate guidance within a phased model that recognizes countries are at different stages of the COVID-19 pandemic. In this perspective paper we propose a phased model of mental health burden and responses. Building on work by the Intensive Care Society and the Royal College of Psychiatrists in the United Kingdom, we present a model that demonstrates how both staff and organizations might respond to the likely stressors that might occur at preparation-, pre-, initial and core-, and longer-termphases of the pandemic. Staff within countries at different stages of the COVID-19 pandemic will be able to use this model. We suggest practical tips for both healthcare workers and organizations and embed this within up-to-date scientific literature. The phased model of mental health burden and responses can be a helpful guide for both staff and organizations operating at different stages of the pandemic.

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Mentally disordered offenders may be sent to secure psychiatric hospitals. These settings can resemble carceral spaces, employing high levels of security restricting resident autonomy, expression and social interaction. However, research exploring the restrictiveness of forensic settings is sparse. A systematic review was therefore undertaken to conceptualize this restrictiveness. Eight databases were searched for papers that address restrictive elements of secure forensic care in a non-cursory way. Fifty sources (empirical articles and policy documents) were included and subject to thematic analysis to identify 1) antecedent conditions to, 2) characteristic attributes, 3) consequences and 4) 'deviant' cases of the developing concept. The restrictiveness of forensic care was experienced across three levels: individual, institutional and systemic. Restrictiveness was subjective and included such disparate elements as limited leave and grounds access, ownership of personal belongings and staff attitudes. The manner and extent to which these are experienced as restrictive was influenced by two antecedent conditions; whether the purpose of forensic care was to be more caring or custodial and the extent to which residents were perceived to be risky. We argue that there must be a reflexivity from stakeholders between the level of restrictiveness needed to safely provide care in a therapeutic milieu and enable the maximum amount of resident autonomy.

Purpose While the number of forensic beds and the duration of psychiatric forensic psychiatric treatment have increased in several European Union (EU) states, this is not observed in others. Patient demographics, average lengths of stay and legal frameworks also differ substantially. The lack of basic epidemiological information on forensic patients and of shared indicators on forensic care within Europe is an obstacle to comparative research. The reasons for such variation are not well understood. Methods Experts from seventeen EU states submitted data on forensic bed prevalence rates, gender distributions and average length of stay in forensic in-patient facilities. Average length of stay and bed prevalence rates were examined for associations with country-level variables including Gross Domestic Product (GDP), expenditure on healthcare, prison population, general psychiatric bed prevalence rates and democracy index scores. Results The data demonstrated substantial differences between states. Average length of stay was approximately ten times greater in the Netherlands than Slovenia. In England and Wales, 18% of patients were female compared to 5% in Slovenia. There was a 17-fold difference in forensic bed rates per 100,000 between the Netherlands and Spain. Exploratory analyses suggested average length of stay was associated with GDP, expenditure on healthcare and democracy index scores. Conclusion The data presented in this study represent the most recent overview of key epidemiological data in forensic services across seventeen EU states. However, systematically collected epidemiological data of good quality remain elusive in forensic psychiatry. States need to develop common definitions and recording practices and contribute to a publicly available database of such epidemiological indicators.

Introduction: Forensic psychiatric care is often practiced in closed institutions. These highly regulated, secure, and prescriptive environments arguably reduce patient autonomy, self-expression, and personhood. Taken together these settings are restrictive as patients' active participation in clinical, organizational, community, and personal life-worlds are curtailed. The consequences of patients' experiences of restrictiveness have not been explored empirically. This study aimed to develop a psychometrically-valid measure of experiences of restrictiveness. This paper presents the development, validation, and revision of the Forensic Restrictiveness Questionnaire (FRQ). Methods: In total, 235 patients recruited from low, medium, and high secure hospitals across England completed the FRQ. The dimensionality of the 56-item FRQ was tested using Principle Axis Factor Analysis and parallel analysis. Internal consistency was explored with Cronbach's α. Ward climate (EssenCES) and quality of life (FQL-SV) questionnaires were completed by participants as indicators of convergent validity. Exploratory Factor Analysis (EFA) and Cronbach's α guided the removal of items that did not scale adequately. Results: The analysis indicated good psychometric properties. EFA revealed a unidimensional structure, suggesting a single latent factor. Convergent validity was confirmed as the FRQ was significantly negatively correlated with quality of life (Spearman's ρ = −0.72) and ward climate (Spearman's ρ = −0.61). Internal consistency was strong (α = 0.93). Forty-one items were removed from the pilot FRQ. The data indicate that a final 15-item FRQ is a valid and internally reliable measure. Conclusion: The FRQ offers a novel and helpful method for clinicians and researchers to measure and explore forensic patients' experiences of restrictiveness within secure hospitals.

Background: A significant proportion of forensic patients in England are long-stayers. This can be problematic as individuals are kept in restrictive environments at potentially inappropriate levels of security for many years, sometimes decades. Improvements to the current English forensic mental health system to meet the needs of long-stay forensic patients more effectively might be informed by the Dutch service for long-stay forensic patients.Aims: To compare the characteristics of representative samples of long-stay patients in England and in the Netherlands in an attempt to draw conclusions on the degree to which the Dutch service model might be relevant to England.Method: This cross-sectional study explores the relevance of the Dutch service model by comparing the characteristics of representative samples of long-stay patients in England (n = 401) and the Netherlands (n = 102). Descriptive statistics and analyses of differences between groups are presented. The Risk-Need-Responsivity model was used to guide the selection of the study variables and structure the interpretation of the findings.Results: Compared to their English counterparts, the long-stay Dutch patients were less likely to be diagnosed with schizophrenia, but more likely to have personality disorder and have committed sex offences. The English group were younger at first conviction and at first custodial sentence. The total number of offences and the proportion of violent offenders were similar, but the Dutch HCR-20 scores indicated a significantly higher risk of violence.Conclusions: Whilst there may be barriers to adopting the Dutch service model in England, the differences in the characteristics of the two groups studied here do not necessarily preclude this approach.

Objectives There is a lack of research informing service delivery for older forensic mental health patients. This study explored service provision in forensic mental health inpatient and community services in England, investigating what is required for progress in terms of quality of life, health, wellbeing, recovery and reduced risk, and the barriers and facilitators associated with this. Methods Semi-structured interviews were undertaken with 48 members of staff working with older forensic mental health patients in secure inpatient units or the community in England. Data were analysed using thematic analysis. Results Two global themes ‘What works’ and ‘What doesn’t work’ were identified comprising themes representing environmental, interpersonal and individual factors. ‘What works’ included: positive social support and relationships; individualised holistic patient-centred care; hub and spoke approach to patient care; and suitable environments. ‘What doesn’t work’ included: absence of/or maladaptive relationships with family and friends; gaps in service provision; and unsuitable environments. Conclusions For older patients to progress to improved quality of life, health, wellbeing and reduced risk, multilevel and comprehensive support is required, comprising a range of services, interventions, and multidisciplinary input, and individualised to each patient’s needs. The physical environment needs to be adapted for older patients and provide a social environment that seeks to include supportive families, friends and expert professional input. A clear patient progression pathway is required; this must be reflected in policy and provision.

Background: Older individuals (e.g., 55 years and over) constitute a growing proportion of the forensic mental health patient population. As a group, they are vulnerable to health outcomes similar to other individuals with serious mental disorders of the same age; however, these concerns can be compounded by complex forensic-related care backgrounds and clinical presentations, lengthy periods of time spent in prison or psychiatric hospitals, substance use histories, and crime perpetration or victimisation. The healthcare needs and strengths of this group are not well understood. The aim of this study was to identify and describe the demographic, physical health, mental wellbeing, cognitive ability, and quality of life profiles of older forensic patients in community, low, medium, and high security settings in England. Methods: A cross-sectional quantitative study design was used. N=37 forensic patients aged 55 years and over completed six questionnaires. Data were also collected from patient records. Results: Most patients were male and were diagnosed with psychosis. The most frequently committed index offence types were violent offences. 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. Patients’ assessments of their recovery-related quality of life and mental wellbeing were comparable to published UK general population values. Assessments of quality of life were positively correlated with the ability to undertake everyday activities and cognitive performance. Conclusions: We suggest that forensic services are well-placed to provide holistic mental and physical care to this group but that they should co-develop with patients a greater range of age-appropriate meaningful activities that are mindful of mobility issues and consider implementing more cognition-based and physical health interventions.