The ongoing debate on the management of personality disordered offenders has been further stimulated by the recently concluded Department of Health and National Offender Management Service joint consultation paper on the proposed personality disorder care pathway. ¹

The Labour government’s flagship Dangerous and Severe Personality Disorder pilot programme is being scaled down at present to make way for national personality disorder services. ^{Reference Duggan2} Approaching the conclusion of the Programme, clinicians are still looking at the most effective treatment regimes and politicians are still striving to ensure that the public protection element of treatment is not overlooked. Both parties are labouring to find the most effective way of managing this group of offenders who are considered to be ‘difficult to treat’, ‘high risk’ and ‘carrying a high morbidity and stigma’.

Thus, we welcome and value the suggestion of early identification and provisions for a suitable care pathway for personality disordered offenders. ¹ A standardised early identification system with clear pathways of treatment is likely to reduce patient distress, risks to the public and long-term costs to the criminal justice and healthcare systems.

Nevertheless, we have concerns regarding the proposal that the diagnostic process and case formulation be undertaken wholly by offender managers along with forensic and clinical psychologists. ¹ Although we value the important contribution from our colleagues in the ongoing management of this group of patients, it is more appropriate that the diagnosis should be carried out by medically qualified doctors, i.e. psychiatrists.

Those who have experience in forensic psychiatric settings appreciate that mentally ill offenders present with complex psychopathologies. The diagnosis and case formulation including management pathways require the corresponding level of experience, training and skill, particularly given the mandatory nature of this patient group’s detention. A percentage of offenders who appear to present with functional mental disorders will in fact be presenting with endocrine, neurological, immunological or other related conditions. This requires medical training to identify. A ‘diagnostic questionnaire’ would be too simplistic, too inaccurate and would potentially lend itself to an underdiagnosis of personality disorder. In addition, if questionnaires and criteria for diagnosis are employed based on the face value, the error then would be an overdiagnosis of personality disorder. This would result in attaching a ‘personality disorder’ label to a selected group of patients. These patients are known to be stigmatised by society and at times excluded from prison treatment programmes, or worst still, marginalised by healthcare services. The presumptive diagnosis often significantly influences the latter stages of a patient’s care pathway. This includes its direction (criminal justice or healthcare), sentencing, custody and the necessary level of health service input at each subsequent stage. A diagnosis achieved by a psychiatrist, whose training as a medical doctor requires years of experience, would surely be better than having significant numbers of patients being inaccurately categorised based on a form.

The skill of the medical doctor is in evaluating the patient as a whole, considering the symptoms and signs while utilising the appropriate diagnostic tools based on current evidence or guidelines. Having achieved a diagnosis, the real utility of a medical doctor is in treating the patient. Knowledge and experience in all medical conditions are therefore essential. This is important for a patient group with very serious psychiatric comorbidities such as psychosis, mood disorders and paraphilias. ^{Reference Coid3} It is accepted that at present treatment regimes for personality disorder are largely psychosocial in nature. However, correct treatment starts with correct diagnosis. In our experience, high psychiatric and physical comorbidities often necessitate the use of medication. Medical treatments for personality disorder and its manifestations (such as emotional lability and aggression) are increasingly being recommended as the evidence base supporting their efficacy expands. ^{Reference Nose, Cipriani, Biancosino, Grassi and Barbui4,Reference Ingenhoven, Lafay, Rinne, Passchier and Duivenvoorden5} The treatment of these symptoms is pertinent in contributing to the patient’s risk reduction and hence future reoffending. The psychiatrist, apart from prescribing physical treatments and having a more holistic view, is able to discuss and refer the patient to other medical and surgical specialties if the need arises. The importance of such medical discussion and conference should not be underestimated, particularly if it relates to aetiology, as a missed or inaccurate diagnosis at the onset would result in repeated assessments conducted at various junctures and with added costs, longer waiting times and escalation of risks.

In our view, a thorough initial diagnosis and case formulation of personality disordered offenders by a psychiatrist is the crucial starting point. Providing the diagnostic expertise deserved by this complex patient group from the earliest stage ensures value for money for the taxpayer, a more accurate risk formulation and, most importantly, a fair and clinically based service for a very vulnerable and stigmatised group of people in our society.