The symptoms of emotional dysregulation associated with the syndrome known as pseudobulbar affect (PBA) can be effectively treated by the sigma, glutamate, and serotonergic agent dextromethorphan combined with quinidine. If the same brain circuits affected in PBA are also compromised in related disorders of emotional expression, dextromethorphan-quinidine and other novel sigma-glutamate-serotonin agents could prove to be novel psychopharmacologic treatments for these conditions as well.

Seclusion may be harmful and traumatic to patients, detrimental to therapeutic relationships, and can result in physical injury to staff. Further, strategies to reduce seclusion have been identified as a potential method of improving cost-effectiveness of psychiatric services. However, developing alternative strategies to seclusion can be difficult. Interventions to reduce seclusion do not lend themselves to evaluation using randomized controlled trials (RCTs), though comprehensive literature reviews have demonstrated considerable non-RCT evidence for interventions to reduce seclusion in psychiatric facilities. In the UK, a recent 5-year evaluation of seclusion practice in a high secure UK hospital revealed reduced rates of seclusion without an increase in adverse incidents. To assess the effect of a novel intervention strategy for reduction of long-term segregation on a high secure, high dependency forensic psychiatry ward in the UK, we introduced a pilot program involving stratified levels of seclusion (“long-term segregation”), multidisciplinary feedback and information sharing, and a bespoke occupational therapy program. Reduced seclusion was demonstrated and staff feedback was mainly positive, indicating increased dynamism and empowerment on the ward. A more structured, stratified approach to seclusion, incorporating multidisciplinary team-working, senior administrative involvement, dynamic risk assessment, and bespoke occupational therapy may lead to a more effective model of reducing seclusion in high secure hospitals and other psychiatric settings. While lacking an evidence base at the level of RCTs, innovative, pragmatic strategies are likely to have an impact at a clinical level and should guide future practice and research.

This systematic review aimed to examine whether neurobiological methods, or other methods independent of clinical judgment, have been investigated to assist decision making in forensic mental health services and, if so, whether this may be a useful strategy for predicting outcomes. OVID-Medline, Embase, and PsychInfo (inception–January 2015) were searched, limiting to English and human studies, using terms relating to “predict,” “outcome,” “psychiatry,” and “forensic” to identify primary research articles reporting on predictors of outcome in forensic mental health services not reliant on clinical judgment/self-report. Fifty studies investigating demographic, neuropsychological/neurophysiological, and biological predictors were identified, reporting on 3 broad outcomes: (i) inpatient violence, (ii) length of stay, (iii) reoffending. Factors associated positively, negatively, and showing no relationship with each outcome were extracted and compiled across studies. Of various demographic predictors examined, the most consistent associations were between previous psychiatric admissions and inpatient violence; a more “severe” offense and a longer length of stay; and young age and reoffending. Poor performance on tests of cognitive control and social cognition predicted inpatient violence while a neurophysiological measure of impulsivity showed utility predicting reoffending. Serum cholesterol and creatine kinase emerged as biological factors with potential to predict future inpatient violence. Research in this field is in its infancy, but investigations conducted to date indicate that using objective markers is a promising strategy to predict clinically significant outcomes.

High violence prevalence is a common concern for forensic psychiatric settings. Categorizing underlying drivers of violence has helped to direct treatment and management efforts toward psychotic, predatory, and impulsively violent psychopathology. This article describes a series of cases in which clozapine provided adequate control of psychosis in women suffering schizophrenia-spectrum disorders. Nevertheless, impulsive violence remained problematic. Add-on methylphenidate was found to be safe and effective in curbing impulsive violent behavior in this select group of patients.