Seminal Papers

Bateman, A. & Fonagy, P. (2008) Eight-year followup of patients treated for borderline personality disorder: mentalization-based treatment versus treatment as usual. American Journal of Psychiatry. 165:631-638.

This study evaluated the effect of mentalization-based treatment by partial hospitalization compared to treatment as usual for borderline personality disorder 8 years after entry into a randomized, controlled trial and 5 years after all mentalization-based treatment was complete.

Patients with 18 months of mentalization-based treatment by partial hospitalization followed by 18 months of maintenance mentalizing group therapy remain better than those receiving treatment as usual, but their general social function remains impaired.

Bateman, A., & Fonagy, P. (2009). Randomised controlled trial of outpatient mentalization-based treatment versu structured clinical management for borderline personality disorder. American Journal of Psychiatry, 1666, 1355-1364.

This randomized controlled trial tested the effectiveness of an 18-month mentalization-based treatment (MBT) approach in an outpatient context against a structured clinical management (SCM) outpatient approach for treatment of borderline personality disorder.

Structured treatments improve outcomes for individuals with borderline personality disorder. A focus on specific psychological processes brings additional benefits to structured clinical support. Mentalization-based treatment is relatively undemanding in terms of training so it may be useful for implementation into general mental health services. Further evaluations by independent research groups are now required.

Caspi A, Houts RM, Belsky DW, Goldman-Mellor SJ, Harrington H, Israel S, et al. (2014) The p factor: one general psychopathology factor in the structure of psychiatric disorders? Clin Psychol Sci. 2: 119-37.

Mental disorders traditionally have been viewed as distinct, episodic, and categorical conditions. This view has been challenged by evidence that many disorders are sequentially comorbid, recurrent/chronic, and exist on a continuum. Using the Dunedin Multidisciplinary Health and Development Study, we examined the structure of psychopathology, taking into account dimensionality, persistence, co-occurrence, and sequential comorbidity of mental disorders across 20 years, from adolescence to midlife. Psychiatric disorders were initially explained by three higher-order factors (Internalizing, Externalizing, and Thought Disorder) but explained even better with one General Psychopathology dimension. We have called this dimension the p factor because it conceptually parallels a familiar dimension in psychological science: the g factor of general intelligence. Higher p scores are associated with more life impairment, greater familiality, worse developmental histories, and more compromised early-life brain function. The p factor explains why it is challenging to find causes, consequences, biomarkers, and treatments with specificity to individual mental disorders. Transdiagnostic approaches may improve research.

Fazel S & Danesh J. 2002. Serious mental disorder in 23000 prisoners: a systematic review of 62 surveys. Lancet 359: 545-50.

About 9 million people are imprisoned worldwide, but the number with serious mental disorders (psychosis, major depression, and antisocial personality disorder) is unknown. We did a systematic review of surveys on such disorders in general prison populations in western countries.

We searched for psychiatric surveys that were based on interviews of unselected prison populations and included diagnoses of psychotic illnesses or major depression within the previous 6 months, or a history of any personality disorder. We did computer-assisted searches, scanned reference lists, searched journals, and corresponded with authors. We determined prevalence rates of serious mental disorders, sex, type of prisoner (detainee or sentenced inmate), and other characteristics.

62 surveys from 12 countries included 22790 prisoners (mean age 29 years, 18530 [81%] men, 2568 [26%] of 9776 were violent offenders). 3.7% of men (95% CI 3.3–4.1) had psychotic illnesses, 10% (9–11) major depression, and 65% (61–68) a personality disorder, including 47% (46–48) with antisocial personality disorder. 4.0% of women (3.2–5.1) had psychotic illnesses, 12% (11–14) major depression, and 42% (38–45) a personality disorder, including 21% (19–23) with antisocial personality disorder. Although there was substantial heterogeneity among studies (especially for antisocial personality disorder), only a small proportion was explained by differences in prevalence rates between detainees and sentenced inmates. Prisoners were several times more likely to have psychosis and major depression, and about ten times more likely to have antisocial personality disorder, than the general population.

Worldwide, several million prisoners probably have serious mental disorders, but how well prison services are addressing these problems is not known.

Fazel, S. & Seewald, K. (2012) Severe mental illness in 33 588 prisoners worldwide: systematic review and meta-regression analysis. The British Journal of Psychiatry, 200 (5) 364-373

High levels of psychiatric morbidity in prisoners have been documented in many countries, but it is not known whether rates of mental illness have been increasing over time or whether the prevalence differs between low-middle-income countries compared with high-income ones.

To systematically review prevalence studies for psychotic illness and major depression in prisoners, provide summary estimates and investigate sources of heterogeneity between studies using meta-regression.

Studies from 1966 to 2010 were identified using ten bibliographic indexes and reference lists. Inclusion criteria were unselected prison samples and that clinical examination or semi-structured instruments were used to make DSM or ICD diagnoses of the relevant disorders.

We identified 109 samples including 33 588 prisoners in 24 countries. Data were meta-analysed using random-effects models, and we found a pooled prevalence of psychosis of 3.6% (95% CI 3.1-4.2) in male prisoners and 3.9% (95% CI 2.7-5.0) in female prisoners. There were high levels of heterogeneity, some of which was explained by studies in low-middle-income countries reporting higher prevalences of psychosis (5.5%, 95% CI 4.2-6.8; P = 0.035 on meta-regression). The pooled prevalence of major depression was 10.2% (95% CI 8.8-11.7) in male prisoners and 14.1% (95% CI 10.2-18.1) in female prisoners. The prevalence of these disorders did not appear to be increasing over time, apart from depression in the USA (P = 0.008). Conclusions
High levels of psychiatric morbidity are consistently reported in prisoners from many countries over four decades. Further research is needed to confirm whether higher rates of mental illness are found in low- and middle-income nations, and examine trends over time within nations with large prison populations.

Glasser, M (1996) The Assessment and Management of Dangerousness: The Psychological Contribution. Journal of Forensic Psychiatry. 7: 271-283.

In the difficulties in assessing dangerousness, the contribution of the psychoanalytical approach should not be overlooked: it can be of great value in diagnosis, treatment, discharge evaluation and management within an institution and in the community.

Hinshelwood, R.D. (1999) The difficult patient. The role of ‘scientific psychiatry’ in understanding patients with chronic schizophrenia or severe personality disorder. British Journal of Psychiatry. 1999 Mar;174:187-90.

The role of ‘scientific psychiatry’ in understanding patients with chronic schizophrenia or sever personality disorder.

Main, T (1957) The Ailment. British Journal of Medical Psychology, 30: 129-145.

Address from the Chair, to the Medical Section, British Psychological Society, on 20 March 1957, in which the author offers a psychoanalytic understanding of the dynamics within teams involved in the treatment of individuals on psychiatric inpatient hospital wards.

Mullen, P. E. (2000) Forensic mental health. The British Journal of Psychiatry. 176 (4) 307-311

In which the author outlines what Forensic Psychiatry is, and some of the key challenges facing the discipline, such as risk assessment and management, service improvement, and workforce development.

Steadman, H.J., Mulvey, E. P., & Monahan, J. (1998) Violence by People Discharged From Acute Psychiatric Inpatient Facilities and by Others in the Same Neighborhoods. Arch Gen Psychiatry. 55(5):393-401.

The public perception that mental disorder is strongly associated with violence drives both legal policy (eg, civil commitment) and social practice (eg, stigma) toward people with mental disorders. This study describes and characterizes the prevalence of community violence in a sample of people discharged from acute psychiatric facilities at 3 sites. At one site, a comparison group of other residents in the same neighborhoods was also assessed.

We enrolled 1136 male and female patients with mental disorders between the ages of 18 and 40 years in a study that monitored violence to others every 10 weeks during their first year after discharge from the hospital. Patient self-reports were augmented by reports from collateral informants and by police and hospital records. The comparison group consisted of 519 people living in the neighborhoods in which the patients resided after hospital discharge. They were interviewed once about violence in the past 10 weeks.Results
There was no significant difference between the prevalence of violence by patients without symptoms of substance abuse and the prevalence of violence by others living in the same neighborhoods who were also without symptoms of substance abuse. Substance abuse symptoms significantly raised the rate of violence in both the patient and the comparison groups, and a higher portion of patients than of others in their neighborhoods reported symptoms of substance abuse. Violence in both patient and comparison groups was most frequently targeted at family members and friends, and most often took place at home.Conclusions 
“Discharged mental patients” do not form a homogeneous group in relation to violence in the community. The prevalence of community violence by people discharged from acute psychiatric facilities varies considerably according to diagnosis and, particularly, co-occurring substance abuse diagnosis or symptoms.