Mental disorder and violence. A special (high security) hospital study

Esquizofrenia, psicopatologia e crime violento: uma revisão das evidências empíricas

OBJETIVO: Estudar, mediante uma revisão sistemática da literatura científica, a relação esquizofrenia, psicose e violência. MÉTODOS: Realizou-se uma busca eletrônica por meio das bases de dados Medline, SciELO e Lilacs, até a data de junho de 2006, considerando artigos de línguas inglesa e portuguesa. RESULTADOS: Um número de pesquisas revela associação entre esquizofrenia e comportamento violento, principalmente quando existe comorbidade com abuso de substâncias. Aspectos específicos dos delírios são relacionados com comportamento violento, como maior grau de convicção e presença de delírios de controle e perseguição. CONCLUSÕES: Apesar de limitações metodológicas, alguns aspectos da psicopatologia aguda da psicose e da comorbidade de abuso de substâncias parecem estar fortemente relacionados à presença de comportamento violento entre pacientes psicóticos. De acordo com os estudos analisados, somente uma pequena parcela da violência social poder ser atribuída a esse grupo de pacientes. Novas pesquisas deverão futuramente permitir prever antecipadamente o risco de um comportamento violento, permitindo com isso intervenções preventivas e redução do processo de estigmatização.

Violence in psychiatric units: a 7-year Italian study of persistently assaultive patients

BACKGROUND

The problem of violence and aggressive behaviour among patients with psychiatric disorders need careful assessment to improve the quality of psychiatric care. The aim of this paper is to describe the characteristics of repeated episodes of violence among patients admitted to an Italian psychiatric ward.

METHODS

All violent behaviours, which occurred in a 15-bed psychiatric inpatient unit over a 7-year period, were assessed by using the Staff Observation Aggression scale (SOAS).

RESULTS

Of a total of 3.507 admissions, 409 aggressive episodes were recorded by 160 patients (rate per admission 11.6%). A total of 65 patients exhibited two or more episodes and 95 patients showed a single episode. Repeatedly violent patients had a higher length of stay in the unit, a higher number of previous admissions and a higher number of previous violent episodes. No difference was found in terms of psychiatric diagnosis, socio-demographic variables, type of admission (voluntary versus involuntary), ward overcrowding and characteristics of violent episodes (means, aims and consequence).

CONCLUSIONS

In spite of the low prevalence of violent incidents among Italian psychiatric inpatients, careful monitoring of clinical variables associated with repeated violent episodes may help physicians recognise and prevent violence episodes among acute psychiatric inpatients.

Managing the aggressive and violent patient in the psychiatric emergency

Throughout history most societies have assumed a link between mental disorders and violence. Although the majority of users of mental health services are not violent, it is clear that a small yet significant minority are violent in inpatient settings and in the community. The assessment of a violent patient may be very difficult due to the lack of a full medical and psychiatric history and the non-cooperativeness of the patient. Thus a full assessment is important for the early decisions that the clinician has to take in a very quick and effective way. The primary task and the short term outcome in a behavioral emergency is to act as soon as possible to stop the violence from escalating and to find the quickest way to keep the patient's agitation and violence under control with the maximum of safety for everybody and using the less severe effective intervention. The pharmacological treatment of acute, persisting and repetitive aggression is a serious problem for other patients and staff members. Currently, there is no medication approved by the Food and Drug Administration (FDA) for the treatment of aggression. Based on rather limited evidence, a wide variety of medications for the pharmacological treatment of acute aggression has been recommended: typical and atypical antipsychotics and benzodiazepines.

Neural dysfunction and violence in schizophrenia: an fMRI investigation

Contemporary theories and evidence implicate frontal lobe dysfunction in violent behaviour as well as in schizophrenia. We applied functional magnetic resonance imaging (fMRI) to investigate and compare brain activation during an 'n-back' working memory task in groups of men with (i) schizophrenia and a history of serious physical violence (VS; n=13), (ii) schizophrenia without a history of violence (NVS: n=12), (iii) antisocial personality disorder (APD) and a history of serious physical violence (n=10), and (iv) no history of violence or a mental disorder (n=13). We observed comparable performance in all four groups during the control (0-back) condition. Subtle working memory deficits were seen in the NVS and APD groups but severe deficits emerged in the VS group relative to the healthy group. The VS group showed activation deficit bilaterally in the frontal lobe and precuneus when compared to the healthy group, and in the right inferior parietal region when compared to the NVS group during the working memory load condition. Frontal (bilateral) as well as right inferior parietal activity was negatively associated with the ratings of violence across all schizophrenia patients, with the right parietal region showing this association most strongly. APD patients, relative to healthy subjects, showed activation deficit in the left frontal gyrus, anterior cingulate and precuneus. It is concluded that reduced functional response in the frontal and inferior parietal regions leads to serious violence in schizophrenia perhaps via impaired executive functioning.

Quantifying the contributions of three types of information to the prediction of criminal conviction using the receiver operating characteristic

BACKGROUND

Quantifying the contributions that different types of information make to the accurate prediction of offending offers the prospects of improved practice and better use of resources.

AIMS

To quantify the contributions made by three types of information--demographic data alone, demographic and criminal record and demographic, criminal record and legal class of disorder--to the prediction of criminal conviction in patients.

METHOD

All 425 patients discharged from the three special (high secure) hospitals in England and Wales over 2 years were followed for 10.5 years. The contribution of each type of information was described in terms of the area under the receiver operating characteristic curve (AUC) and the number needed to detain (NND).

RESULTS

The AUC values using the three types of information were 0.66, 0.72 and 0.73 respectively. Prediction based on the full model using an optimal probability cut-off implies an NND of 2. The AUCs for serious offences were 0.67, 0.69 and 0.75 respectively.

CONCLUSIONS

For long-term prediction of conviction on any charge, information on legal class adds little to the accuracy of predictions made using only a patient's age, gender and criminal record. In the prediction of serious offences alone the contribution of legal class is significant.

Volumetric structural brain abnormalities in men with schizophrenia or antisocial personality disorder

Brain abnormalities are found in association with antisocial personality disorder and schizophrenia, the two mental disorders most implicated in violent behaviour. Structural magnetic resonance imaging was used to investigate the whole brain, cerebellum, temporal lobe, lateral ventricles, caudate nucleus, putamen, thalamus, hippocampus, amygdala and the prefrontal, pre-motor, sensorimotor, occipito-parietal regions in 13 men with antisocial personality disorder, 13 men with schizophrenia and a history of violence, 15 men with schizophrenia without violent history and 15 healthy non-violent men. Compared to controls, the antisocial personality disorder group displayed reductions in whole brain volume and temporal lobe as well as increases in putamen volume. Both schizophrenia groups regardless of violence history exhibited increased lateral ventricle volume, while the schizophrenia group with violent history showed further abnormalities including reduced whole brain and hippocampal volumes and increased putamen size. The findings suggest that individuals with antisocial personality disorder as well as those with schizophrenia and a history of violence have common neural abnormalities, but also show neuro-anatomical differences. The processes by which they came to apparently common ground may, however, differ. The finding of temporal lobe reductions prevalent among those with antisocial personality disorder and hippocampal reduction in the violent men with schizophrenia contributes support for the importance of this region in mediating violent behaviour.

"Stereotypic" delusional offending

Some patients with serious mental illness appear to respond violently to the same delusional content throughout the course of their illness. Anecdotal, empirical, and theoretical evidence is presented establishing the premise of "stereotypic" delusional offending. A method for measuring the similarity of two delusions separated in time also is presented. An empirical focus on stereotypic delusional offending may help identify more accurately persons at risk for violence and those at risk for becoming targets of violence. It also may provide a better understanding of successful treatment of outpatient violence and conceivably could inform the ongoing debate on involuntary outpatient commitment laws. Among the major issues of this debate in the United States are the potential benefits of a forced medication provision. One rationale for such a provision may be found in the treatment response of seriously mentally ill outpatients whose violent behavior appears inescapably tied to their persistent or recurrent delusions.

Excessive violence and psychotic symptomatology among homicide offenders with schizophrenia

BACKGROUND

It is not currently known how psychotic symptoms are associated with the nature of violence among homicide offenders with schizophrenia, or, more specifically, whether different psychotic symptoms are differentially linked with excessive violence.

AIM

To identify factors associated with the use of excessive violence among homicide offenders with schizophrenia.

METHODS

Forensic psychiatric examination statements and Criminal Index File data of 125 consecutive Finnish homicide offenders with a diagnosis of schizophrenia were analysed.

RESULTS

Nearly one-third of the cases in this sample involved extreme violence, including features such as sadism, mutilation, sexual components or multiple stabbings. Excessive violence was a feature of acts when the offender was not the sole perpetrator or when there was a previous homicidal history. Positive psychotic symptoms, including delusions, were not associated with the use of excessive violence.

CONCLUSIONS

These results highlight the importance of variables other than clinical state when examining qualitative aspects of homicidal acts, such as the degree and nature of violence, by offenders with schizophrenia. Further study is needed with a more specific focus on the qualities of the violence among different subgroups of offenders, but inclusive of those with psychosis.

Delusional disorder and delusions: is there a risk of violence in social interactions about the core symptom?

Delusional disorders are rare, but psychoses with prominent and persistent delusions are less so. A small but significant association between psychosis and violence is often mediated by delusions in such illnesses. Traditionally, delusions have been viewed as "incorrigible", but there is evidence that they change over time. During development of a scale for measuring delusions, it was found that people who acted violently on their "most important" delusion were more likely to have modified that belief after a mild form of challenge to it. When cognitive-behaviour therapy (CBT) is used for schizophrenia, attempts to modify psychotic symptoms are generally included. Could studies of CBT provide further information about possible risks of social interactions about delusions?In the UK, 2000 people with schizophrenia have been in randomized controlled trials of CBT with a goal of symptom modification. These studies were examined for evidence of violence during the treatment. There was none. Given the period prevalence of violence among people with psychosis, this is surprising. In these studies, however, both challenge to delusions and change in them was minimal and in the context of a safe clinical relationship. Challenge to delusions may, however, occur in a variety of social situations. There are no systematic data on lay challenge to them, but it seems likely that some in the sufferer's social circle will do so vigorously. Relatives, friends, and acquaintances are the people most vulnerable to the most serious violence by someone with psychosis. Study of how people interact in these circumstances and whether their interactions are relevant to modification of delusions would be worthwhile. Could those close to a sufferer learn skills for responding to such pathological beliefs that could be protective against violence, perhaps derived from the principles of CBT?

Crime, diagnóstico psiquiátrico e perfil da vítima: um estudo com a população de uma casa de custódia do estado de São Paulo

OBJETIVO: Estudar a população de uma casa de custódia quanto a aspectos criminais, diagnóstico clínico e perfil da vítima. MÉTODOS: Foram examinados os prontuários de 269 pacientes durante o ano de 2005. Considerou-se apenas a população do gênero masculino cujos casos já tinham laudo anexado ao prontuário psiquiátrico-criminal. RESULTADOS: Foi encontrado predomínio de transtornos psicóticos (58%). O crime mais freqüente foi contra a vida (52,8%), sendo o grupo dos pacientes psicóticos o que teve maior associação com esse tipo de crime (p < 0,05). Desses crimes, 89,7% resultaram em morte e em 34,5% a vítima era um parente próximo. Os sujeitos com retardo mental cometeram proporcionalmente mais crimes sexuais quando comparados com os pacientes psicóticos e considerando somente crime sexual ou contra a vida (p < 0,05). Em 78,5% dos crimes sexuais as vítimas tinham idade inferior a 14 anos. CONCLUSÃO: A população estudada é semelhante às de outras instituições com o mesmo perfil. Os achados em relação às características das vítimas, tanto nos casos de homicídio pelos psicóticos como nos crimes sexuais dos sujeitos com retardo mental, indicam que aspectos da vítima têm papel importante no crime.

Combining clinical and actuarial methods to assess and manage risk in a New South Wales forensic psychiatric setting

OBJECTIVE

This paper describes the risk assessment (RA) approach in a maximum security forensic psychiatric unit in New South Wales, Australia. The literature in relation to violence and mental illness is briefly reviewed and discussed and the process of RA is described. Emphasis is placed on the importance of combining clinical and actuarial methods to engage in comprehensive RA.

CONCLUSION

It is concluded that a combination of actuarial and clinical assessment completed by a multidisciplinary team of mental health professionals with clinical knowledge of the patient being assessed is proving to be an efficient and effective method. Further directions are highlighted and a cautionary note in relation to the potential for unintended outcomes is made.

Prediction of inpatient violence

OBJECTIVE

An overview of studies on predictors and on the accuracy of prediction of inpatient violence should be given.

METHOD

To date, the published data do not allow a systematic meta-analysis due to different sample characteristics, different measures and definitions of violence, and different time frames of observation. Published studies were reviewed regarding significant predictors of inpatient violence.

RESULTS

Predictors of violence in institutional settings are different from predictors of violence in the community: variables such as sex, age, diagnosis and alcohol abuse play a minor role, while clinical and psychopathological variables are prominent. Only history of violence is a robust static predictor. The total level of positive and general psychotic symptoms seems to enhance the violence risk of inpatients, whereas results concerning specific features like delusions or command hallucinations are contradictory due to inevitable problems of sample selection. The accuracy of clinical predictions is better than chance but limited by the effects of therapeutic interventions and research artefacts.

CONCLUSION

The author argues that more precise determinations of the violence risk in institutions will fail and that the role of environmental factors has often been underestimated.

Association between violent behaviour and impaired prepulse inhibition of the startle response in antisocial personality disorder and schizophrenia

Violent behaviour has a strong association with antisocial personality disorder (APD) and schizophrenia. Although developments in the understanding of socio-environmental factors associated with violence should not be ignored, advances in prevention and treatment of violent behaviour would benefit by improved understanding of its neurobiological and cognitive basis. The authors, therefore, investigated prepulse inhibition (PPI) of the startle response in APD and schizophrenia in relation to a history of serious violence. The neural substrates of PPI, especially the hippocampus, amygdala, thalamus and basal ganglia, are implicated in violence as well as in APD and schizophrenia. The study included four groups: (i) patients with APD and a history of violence, (ii) patients with schizophrenia and a history of violence, (iii) patients with schizophrenia without a history of violence, and (iv) healthy subjects with no history of violence or a mental disorder. All subjects were assessed identically on acoustic PPI. Compared to healthy subjects, significantly reduced PPI occurred in APD, violent schizophrenia and non-violent schizophrenia patients. Although PPI did not significantly differentiate the three clinical groups, high ratings of violence were modestly associated with reduced PPI across the entire study sample. Violent patients with impulsive and premeditated violence showed comparable PPI. The association between violent behaviour and impaired PPI suggests that neural structures and functions underlying PPI are implicated in (inhibition of) violence.

Clotiapine for acute psychotic illnesses

BACKGROUND

Acute psychotic illnesses, especially when associated with agitated or violent behaviour, require urgent pharmacological tranquillisation or sedation. Clotiapine, a dibenzothiazepine neuroleptic, is being used for this purpose in several countries.

OBJECTIVES

To estimate the effects of clotiapine when compared to other 'standard' or 'non-standard' treatments for acute psychotic illnesses in controlling disturbed behaviour and reducing psychotic symptoms.

SEARCH STRATEGY

We updated previous searches by searching the Cochrane Schizophrenia Group Register (April 2004)

SELECTION CRITERIA

The review included randomised clinical trials comparing clotiapine with any other treatment for people with acute psychotic illnesses.

DATA COLLECTION AND ANALYSIS

Relevant studies were selected for inclusion, their quality was assessed and data extracted. Data were excluded where more than 50% of participants in any group were lost to follow up. For binary outcomes we calculated a standard estimation of the risk ratio (RR) and its 95% confidence interval (CI). For continuous outcomes, endpoint data were preferred to change data. Non-skewed data from valid scales were summated using a weighted mean difference (WMD).

MAIN RESULTS

We identified five relevant trials. None compared clotiapine with placebo, but control drugs were either antipsychotics (chlorpromazine, perphenazine, trifluoperazine and zuclopenthixol acetate) or benzodiazepines (lorazepam). Versus the antipsychotics, the results for 'no important global improvement' did not suggest clotiapine to be superior, or inferior, to chlorpromazine, perphenazine, or trifluoperazine (n = 83, 3 RCTs, RR 0.82 CI 0.22 to 3.05, I-squared 58%). Use of clotiapine when compared with chlorpromazine did change the proportion of people ready for hospital discharge by the end of the study (n = 49, 1 RCT, RR 1.04 95%CI 0.96 to 2.12). Overall, attrition rates were low. No significant difference was found for those allocated to clotiapine compared with people randomised to other antipsychotics (n = 121, RR 2.26 95%CI 0.40 to 13). Weak data suggests that clotiapine may result in less need for antiparkinsonian treatment compared with zuclopenthixol acetate (n = 38, RR 0.43 95%CI 0.02 to 0.98). Compared with lorazepam, clotiapine, when used to control aggressive/violent outbursts for people already treated with haloperidol, did not significantly improve mental state (WMD -3.36 95%CI -8.09 to 1.37). We could not pool much data due to skew or inadequate presentation of results. Economic outcomes and satisfaction with care were not addressed.

REVIEWERS' CONCLUSIONS

We found no evidence to support the use of clotiapine in preference to other 'standard' or 'non-standard' treatments for management of people with acute psychotic illness. All trials in this review have important methodological problems. We do not wish to discourage clinicians from using clotiapine in the psychiatric emergency, but well-designed, conducted and reported trials are needed to properly determine the efficacy of this drug.

New evidence or changing population? Reviewing the evidence of a link between mental illness and violence

There has been an apparent shift in majority opinion within psychiatry over the last 20 years on the nature of the relationship between mental illness and violence. Where once there was perhaps widespread scepticism, research, while sometimes producing conflicting results, appears ultimately to have led to the emergence of an almost universal consensus that there is a link. This paper will review the nature of the evidence for such a link between mental illness and violence and explore some of the newer suggestions about why mental illness may sometimes be related to violence.

Treatment of the psychotic patient who is violent

Aggression among patients with serious mental illness occurs relatively infrequently, but it is a significant concern for patients, relatives, mental health professionals, and the public. Recognition of this risk and providing access and continuity of appropriate psychiatric care should be major clinical and administrative objectives in the management of violence in psychotic patients. To date, pharmacologic approaches have been unclear and inconsistent. At present, typical antipsychotics continue to have a primary role in acute management and in long-term management, in which noncompliance necessitates the use of long-acting depot neuroleptic preparations. Atypical antipsychotics in acute and long-acting intramuscular forms doubtless will influence and expand the choice for acute management of hostile psychotic patients and the long-term management of poorly compliant patients who are at risk to become violent on relapse. Persistent aggression should be managed by atypical antipsychotics with a preferential indication for clozapine, for which the most data on efficacy are available. The role of adjunctive medications is presently unclear. A major focus of care should be to refine legal processes and to conduct intervention studies aimed at enhancing treatment compliance. Violence risk reduction is not only crucial from a societal perspective, but also it is a humanitarian necessity to alleviate the burden and stigma for patients with serious mental illness.

Referred to high secure care: determinants of a bed offer/admission and placement after one year

BACKGROUND

The admission process to high secure care ought to ensure that those admitted (a) receive mental health care that meets their needs and (b) that this is provided at an appropriate level of security.

AIMS

A study was undertaken to test the effectiveness of the gate keeping process according to these two criteria. METHOD All referrals for admission to Rampton high security hospital over one year were examined and, in addition, all women, all Anglo-Caribbeans and a random 50% sample of the Caucasian male majority were selected for interview. Each case was followed up for 12 months following the panel decision to determine his/her placement at that time.

RESULTS

Of 138 referred, 56 (41%) were initially offered a bed although nearly half (66) had been subsequently admitted by the end of the study period. Seriousness of mental disorder and offence were independently associated with admission. After one year, one third of those admitted were no longer in high secure care.

CONCLUSIONS

The variables predictive of admission (i.e. seriousness of both mental disorder and offence) suggest that the decision-making process was valid. Placement at 12 months tended to endorse the decision not to offer a bed, but it is more difficult to interpret the reverse as short admissions to high security for those who left within 12 months may have been appropriate. There was no apparent advantage in having a panel reviewing the decision of the assessing clinician.

Children admitted to high security (special) hospital

INTRODUCTION

The Special Hospitals in England provide psychiatric treatment in high security. The aim of this study was to examine the demographics and background characteristics of children admitted to high security hospitals in England, using the special hospital case register.

METHOD

Forty-six children (the subject group) were admitted to a high security hospital under the MHA (1983) classification of disorder of mental illness and/or psychopathic disorder between 1983 and 1999, 33 (72%) of whom were male. A comparison group of adults was matched on sex, legal classification of detention and MHA 1983 classification of disorder.

RESULTS

The children were admitted for a similar range of offences to those of the comparison group. However, the children had received convictions for criminal damage and violence at a significantly earlier age, they were more likely to have experienced a change in caregiver during their childhood, been placed in a children's home and were less likely to be living with a family member on their 16th birthday. Children admitted to special hospital experience a lot of disruption in their childhood and are extremely high users of multi-agency services as they grow up.

DISCUSSION

Issues are raised regarding how to provide a developmentally sensitive service for children who require high security care.

Mental disorder and perceived threat to the public: people who do not return to community living

BACKGROUND

In the UK, people with mental disorder thought to pose a high risk of harm to others are usually put in a high-security (special) hospital. Little is known about what happens after that.

AIMS

To test a hypothesis that, under current services and laws (from the mid-1980s), no one leaving high-security hospitals remains indefinitely institutionalised.

METHOD

The special hospitals' case register was used for case ascertainment and admission data; post-discharge data were collected from multiple sources on patients discharged in 1984 (census date 31.12.1995).

RESULTS

In this discharge cohort (n=223), 36 (17%) did not return to the community: 17 died in special hospital and 19 continuously lived in other institutions until death or the census date. Over two-thirds of these had mental illness, were older on admission and had lived longer in special hospital than their better-rehabilitated peers. Offending history was irrelevant to this. Most post-discharge institution time was in open psychiatric hospital, or back in special hospital, not in medium secure units or prison.

CONCLUSIONS

The hypothesis was not sustained, but fewer people never reached the community than before the mid-1980s. Atypical antipsychotics might reduce this number. We found no justification for a new tier of long-term medium secure units.

Neuroimaging violence in the mentally ill: what can it tell us?

Incidents of aggression and violence in severe mental disorders like psychosis, personality disorders and substance misuse disorders are higher than in the general population. Recent advances in neuroimaging techniques may help to predict violent behaviour in mentally ill individuals and to identify anomalies in brain functioning that may be amenable to treatment.

Psychosis in high-security and general psychiatric services: report from the UK700 and special hospitals' treatment resistant schizophrenia groups

BACKGROUND

Serious violence is an unusual but significant correlate of psychosis, and leads to the need for specialist secure psychiatric services. Most such service users have previously used general psychiatric services.

AIMS

To examine diagnostic and socio-demographic differences between high-security psychiatric service users from their peers in community services.

METHOD

Two groups of patients with psychosis were compared: a national sample of high-security hospital residents, and a sample of patients in contact with general psychiatric services.

RESULTS

Schizophrenia was the almost invariable diagnosis for all special hospital patients. White patients in the community sample were significantly more likely to have affective components to their illness compared with African-Caribbean patients; unlike those in special hospitals. There was a small excess in the proportion of African-Caribbean patients in the special hospital group, controlling for diagnosis, gender and locality. Men were overrepresented in this group.

CONCLUSIONS

Among patients with psychosis, having a diagnosis of schizophrenia and being male increase the likelihood of special hospital admission. Suggestions that ethnic minority patients are much more likely to have engaged in serious violence and need high-security placement were not borne out.

Identification of quantitative trait Loci that affect aggressive behavior in mice

Despite the previous development of single-gene knock-out mice that exhibit alterations in aggressive behavior, very little progress has been made toward identifying the natural gene variants (alleles) that contribute to individual or strain differences in aggression. Whereas most inbred mouse strains show an intermediate level of inter-male aggression in the resident-intruder or dangler behavioral tests, NZB/B1NJ mice are extremely aggressive and A/J mice are extremely unaggressive. We took advantage of the large phenotypic difference between these strains and used an outcross-backcross breeding protocol and a genome-wide scan to identify aggression quantitative trait loci (QTLs) on distal chromosome 10 (Aggr1; p = 6 x 10(-7)) and proximal chromosome X (Aggr2; p = 2.14 x 10(-5)). Candidate genes for Aggr1 and Aggr2, respectively, include the diacylglycerol kinase alpha subunit gene (Dagk1) and the glutamate receptor subunit AMPA3 gene (Gria3). This is the first report of significant aggression QTLs established through a genome-wide scan in any mammal. The mapping of these QTLs is a step toward the definitive identification of mouse alleles that affect aggression and may lead, ultimately, to the discovery of homologous alleles that affect individual differences in aggression within other mammalian species.

[Predicting length of stay in Italian Psychiatric Forensic Hospitals: a survival analysis]

Admission to an Italian Forensic Hospital (OPG) results in formal exit from psychiatric care provided by NHS community based psychiatric services. The length of stay in such facilities is often perceived as a factor negatively affecting the opportunity for reintegration in the community.

METHOD

Factors predicting length of stay in OPG were investigated by means of a survival analysis carried out on a cohort of 118 inmates of three OPGs (Castiglione delle Stiviere, Reggio Emilia and Montelupo Fiorentino), who represent the whole forensic population from 3 different geographical areas at 30.06.97; all discharges occurred in the following 18 months were examined.

RESULTS

In survival analyses conducted on individual predictors, five variables predicted a longer stay: type of offenses (homicide: 706.6 weeks vs. 307.1 for minor offenses and 194.7 for grievous bodily harm, log-rank = 31.8, p < 0.001), type of admission (RR = 0.98, CI 95% 0.97-0.99, p < 0.001), the diagnosis of schizophrenia (621.9 weeks vs. 398.9 weeks or less for other diagnoses; log rank = 9.08, df = 3, p = 0.028), BPRS thought disturbance score (RR = 0.89, CI 98% 0.81-0.98, p < 0.01), hospital of stay (314.6 weeks in Montelupo Fiorentino vs. 706.6 for Reggio Emilia and 621.9 for Castiglione delle Stiviere; log-rank = 9.64, df = 2, p < 0.001). In a Cox linear regression model three significant factors were selected: type of offenses stype of admission, diagnosis of schizophrenia.

CONCLUSIONS

Judicial factors are relevant in determining the length of stay in OPG. The diagnosis of schizophrenia seems to play an independent role in predicting a longer stay.

Effectiveness of ECT combined with risperidone against aggression in schizophrenia

Aggressive behavior in schizophrenic patients can often be problematic not only for the patients themselves, but for their families and others. This study examined the effect of electroconvulsive therapy (ECT) in combination with risperidone in an open trial in 10 male schizophrenic patients with significant aggressive behaviors. Patients were given bilateral ECT five times a week in combination with risperidone. The mean total number of times of ECT was 6.6 (range 5-9). The aggressive behavior in five of the six patients, who showed positive symptoms, was rapidly ameliorated within 12 days. The ECT/risperidone regimen also eliminated aggressive behavior in four patients showing no positive symptoms within 10 days. These treatment effects lasted for at least 6 months in 9 (of the 10) patients. The results suggest that ECT, combined with risperidone, produce a rapid and effective elimination of aggressive behaviors in schizophrenic patients. In addition, there was a resolution of aggression in four patients with no positive symptoms. This suggests that aggression in some schizophrenic patients develops as a primary symptom of schizophrenia and is not related to other positive symptoms of the disease or the patient's personality traits.

The use of trial leave for restricted special hospital patients

INTRODUCTION: For England and Wales, Section 17 of the Mental Health Act 1983 allows for compulsorily detained patients to have trial leave (TL) between hospitals or from hospital to community to allow a period of testing readiness for a change in residency and/or legal status. The aim of this study was to document the use of TL for the largest sub-group of such patients within two discharge cohorts from one high security hospital and to test for correlates. METHOD: Data were collected from the special hospitals' case register for two Broadmoor Hospital discharge cohorts, 1984 and 1990-94, of offender patients with hospital orders under Home Office restrictions on discharge (Section 37/41). RESULTS: In 1984, only two of the 29 people leaving special hospital did so under trial leave arrangements, but by 1990 to 1994, 71% of restricted hospital order departures were under trial leave (92/130), a significant change in practice. Focusing on only the later cohort, women were disproportionately more likely to leave in this way. Trial leave was used more for patients with an index offence of homicide, similarly for violent offences but less so for sex offences. Nature of disorder did not have any bearing on the use of trial leave. Use of trial leave did not significantly shorten length of stay within the special hospital. CONCLUSION: Trial leave has become the most usual route out of special hospital, and is the departure route used almost exclusively for women patients, yet there appears to be no obvious advantage for the patient in shortening length of stay in high security. However, there is no way of knowing how long patients would have stayed had the option of trial leave not been available to them. Furthermore, no advantage for the public was found in the preferential use of TL for discharges to the community.

Psychosis and offending in British Columbia: characteristics of a secure hospital population

INTRODUCTION: There is an increased likelihood of violence in the mentally ill although the risk is small. AIMS: The study aimed to ascertain the features in a secure hospital population that linked offending and mental illness. METHOD: A survey of patients in the high security hospital serving the province of British Columbia in Canada was carried out. Information on 175 mentally disordered offenders was extracted and included demographic data and specific characteristics of their offences, diagnoses and psychotic symptoms. RESULTS: The most prevalent offences were crimes of violence, but 39% of patients were not primarily violent offenders. Almost two-thirds (61%) had two or more diagnoses. A large majority of the patients were psychotic, schizophrenia being the most common diagnosis. There was a highly significant association between psychosis and violence, but the strength of the association was not increased by the presence of imperative hallucinations or delusions. The sample comprised various ethnic groups, one of which, Native Americans, was over-represented. However, no association was found between violent offending and ethnicity, or age or years of illness. DISCUSSION: The study replicates previous findings of the link between violent offending and psychosis, but not a specific link between violent offending and psychotic drive. A surprising finding was a lack of association between violent offences and substance misuse.

Clotiapine for acute psychotic illnesses

BACKGROUND

Acute psychotic illness, especially when associated with agitated or violent behaviour, requires urgent pharmacological tranquillisation or sedation. Clotiapine, a dibenzothiazepine neuroleptic, is being used for this purpose in several countries.

OBJECTIVES

To estimate the effects of clotiapine when compared to other 'standard' or 'non-standard' treatments of acute psychotic illness in controlling disturbed behaviour and reducing psychotic symptoms.

SEARCH STRATEGY

The Cochrane Controlled Trials Register (Issue 2, 2000), The Cochrane Schizophrenia Group's Register (May 2000), EMBASE (1980-2000), MEDLINE (1966-2000), PASCAL (1973-2000) and PsycLIT (1970-2000) were methodically searched. This was supplemented by hand searching reference lists, contacting industry and relevant authors.

SELECTION CRITERIA

Randomised clinical trials comparing clotiapine to any treatment, for people with acute psychotic illnesses such as in schizophrenia, schizoaffective disorder, mixed affective disorders, manic phase of bipolar disorder, brief psychotic episode or organic psychosis following substance abuse.

DATA COLLECTION AND ANALYSIS

Studies were reliably selected, quality assessed and data extracted. Data were excluded where more than 50% of participants in any group were lost to follow up. For binary outcomes a standard estimation of the risk ratio (RR) and its 95% confidence interval (CI) was calculated. Where possible, the weighted number needed to treat statistic (NNT), and its 95% confidence interval (CI), was also calculated. If heterogeneity was found, a random effects model was used. For continuous outcomes, endpoint data were preferred to change data. Non-skewed data from valid scales were summated using a weighted mean difference (WMD). Again, if heterogeneity was found a random effects model was used. A Mantel-Haenszel chi-square test was used to investigate the possibility of heterogeneity.

MAIN RESULTS

Five trials were included. None compared clotiapine with placebo, but control drugs were either antipsychotics (chlorpromazine, perphenazine, trifluoperazine and zuclopenthixol acetate) or benzodiazepines (lorazepam). Versus antipsychotics: results for global clinical outcome were heterogeneous (p=0.09) but did not suggest clotiapine to be superior, or inferior, to chlorpromazine, perphenazine, or trifluoperazine (total randomised = 83). Use of clotiapine did change the proportion of people ready for hospital discharge by the end of the study in one small trial (n=49, RR 1.04 95%CI 0.96 to 2.12). Overall, attrition rates were low. No significant difference was found for those allocated to clotiapine compared with people randomised to other antipsychotics (n=121, RR 2.26 95%CI 0.40 to 13). Weak data suggests that clotiapine may result in less need for antiparkinsonian treatment compared with zuclopenthixol acetate (n=38, RR 0.43 95%CI 0.02 to 0.98). Versus lorazepam: when used to control aggressive/violent outbursts for people already treated with haloperidol, clotiapine did not significantly improve mental state compared to lorazepam (WMD -3.36 95%CI -8.09 to 1.37). Much data could not be pooled due to skew or inadequate presentation of results. Economic outcomes and satisfaction with care were not addressed.

REVIEWER'S CONCLUSIONS

We found no significant evidence to support the use of clotiapine rather than other 'standard' or 'non-standard' treatments for the management of acute psychotic illness. The trials included in this review all present important methodological flaws. We do not wish to discourage clinicians from using clotiapine in the psychiatric emergency, we would just like to point out the fact that good quality controlled trials are needed on this subject.

Prefrontal and medial temporal correlates of repetitive violence to self and others

BACKGROUND

The neurobiological basis for violence in humans is poorly understood, yet violent behavior (to self or others) is associated with large social and healthcare costs in some groups of patients (e.g., the mentally retarded). The prefrontal cortex and amygdalo-hippocampal complex (AHC) are implicated in the control aggression, therefore we examined the neural integrity of these regions in violent patients with mild mental retardation and nonviolent control subjects.

METHODS

We used (1)H-magnetic resonance spectroscopy (MRS) to measure 1) concentrations and ratios of N-acetyl aspartate (NAA), creatine phosphocreatine (Cr+PCr), and choline-related compounds (Cho) in prefrontal lobe of 10 violent inpatients and 8 control subjects; 2) ratios of NAA, Cr+PCr, and Cho in the AHC of 13 inpatients and 14 control subjects; and 3) frequency and severity of violence in patients.

RESULTS

Compared to control subjects, violent patients had significantly (p <.05, analysis of covariance-age and IQ as confounding covariates) lower prefrontal concentrations of NAA and Cr+PCr, and a lower ratio of NAA/Cr+PCr in the AHC. Within the violent patient group, frequency of observed violence to others correlated significantly with prefrontal lobe NAA concentration (r = -0.72, p <.05).

CONCLUSIONS

NAA concentration indicates neuronal density, and Cr+PCr concentration high-energy phosphate metabolism. Our findings suggest that violent patients with mild mental retardation have reduced neuronal density, and abnormal phosphate metabolism in prefrontal lobe and AHC compared to nonviolent control subjects. Further studies are needed, however, to determine if these findings are regionally specific, or generalize to other groups of violent individuals.

Trends in special (high-security) hospitals. 2: Residency and discharge episodes, 1986-1995

BACKGROUND

It has been argued that many patients in special hospital beds do not need to be there. In the 1990s there were initiatives to discharge women and people with learning difficulties.

AIMS

To test for trends in special hospital discharges and to examine annual resident cohorts.

METHOD

This study was from case registers and hospital records. The main measures were numbers and annual rates for referrals and beds offered; the Mental Health Act 1983 (MHA) classification of mental disorder; adjusted population rates by region; admission episodes; legal category of detention; admission source and type of offence.

RESULTS

The median annual number of residents was 1859 (range 1697-1910), with an 8% fall for the period. This particularly affected people in mental impairment categories. Numbers were sustained in the male mental illness groups. Discharges, mainly to other institutions, increased. There was no overall change over the 10 years in length of stay for treatment, but successive admission cohorts from 1986 did show some reduction, even with solely remand order cases excluded.

CONCLUSIONS

Service planners need a longitudinal perspective on service use. Trends over 10 years to both fewer admissions and more discharges have reduced the special hospital population, but despite new treatments for schizophrenia, men under mental illness classification, as well as transfer from other secure settings, have gone against this trend.

Route of discharge for special (high-security) hospital patients with personality disorder. Relationship with re-conviction

BACKGROUND

A considerable proportion of patients with personality disorder are discharged directly to the community from special (high-security) hospitals.

AIMS

To examine whether patients with personality disorder discharged directly to the community are more likely to be re-convicted than those transferred to psychiatric hospitals of lesser security.

METHOD

Re-conviction data for a five- to nine-year follow-up were collected for a four-year (1988-1991) special hospital discharge cohort of patients with personality disorder.

RESULTS

Individuals discharged directly to the community were not significantly more likely to be re-convicted than those transferred to less secure psychiatric hospitals. However, patients discharged to the community without formal conditions of supervision were more likely to be re-convicted than those discharged to the community with conditions or those transferred to other psychiatric hospitals.

CONCLUSIONS

Formal supervision after discharge may be more important than actual destination in influencing the likelihood of re-conviction.

Serious sex offending against women by men with schizophrenia. Relationship of illness and psychotic symptoms to offending

BACKGROUND

Little is known about men who commit sex offences in the context of psychosis.

AIMS

To examine the relationship of illness and psychotic symptoms to sex offending in men with schizophrenia.

METHOD

A search of Home Office records was completed for all 84 male restricted hospital order in-patients with schizophrenia, resident in any hospital in England and Wales during May 1997, with an index conviction for a contact sex offence against a woman.

RESULTS

At the time of their index offences 80 men were psychotic and half of them had delusions or hallucinations related to the offences. Specific delusional or hallucinatory drive was pertinent in only 18 men but the majority of men committed their first sex offence after onset of schizophrenia. Exclusive sex offending was uncommon.

CONCLUSIONS

When a man with schizophrenia commits a serious sex offence the illness is, more commonly than not, relevant to that offence even though a direct symptom relationship may be relatively unusual.

Homicides by people with mental illness: myth and reality

BACKGROUND

Tragic and high profile killings by people with mental illness have been used to suggest that the community care model for mental health services has failed.

AIMS

To consider whether such homicides have become more frequent as psychiatric services have changed.

METHOD

Data were extracted from Home Office-generated criminal statistics for England and Wales between 1957 and 1995 and subjected to trends analysis.

RESULTS

There was little fluctuation in numbers of people with a mental illness committing criminal homicide over the 38 years studied, and a 3% annual decline in their contribution to the official statistics.

CONCLUSIONS

There are many reasons for improving the resources and quality of care for people with a mental disorder, but there is no evidence that it is anything but stigmatising to claim that their living in the community is a dangerous experiment that should be reversed. There appears to be some case for specially focused improvement of services for people with a personality disorder and/or substance misuse.