Experiences of victimisation and depression are associated with community functioning among men with schizophrenia

Internet-based emotion regulation training aimed at reducing violent revictimization and depressive symptoms in victimized depressed patients: Results of a randomized controlled trial

BACKGROUND

Depressed patients who have become victim of violence are prone to revictimization. However, no evidence-based interventions aimed at reducing revictimization in this group exist.

METHODS

This multicenter randomized controlled trial evaluated the effectiveness of an internet-based emotion regulation training (iERT) added to TAU in reducing revictimization, emotion dysregulation, and depressive symptoms in recently victimized, depressed patients compared to TAU alone. Adult outpatients (N = 153) with a depressive disorder who had experienced threat, physical assault, or sexual assault within the previous three years were randomly allocated to TAU+iERT (n = 74) or TAU (n = 79). TAU involved psychotherapy (mainly cognitive behavioral therapy [77.8 %]). iERT comprised six guided online sessions focused on the acquisition of adaptive emotion regulation skills. The primary outcome measure was the number of revictimization incidents at 12 months after baseline, measured with the Safety Monitor. Analyses were performed according to the intention-to-treat principle.

RESULTS

Both groups showed a large decrease in victimization incidents. Mixed-model negative binomial regression analyses showed that TAU+iERT was not effective in reducing revictimization compared to TAU (IRR = 0.97; 95%CI = 0.64,1.46; p = .886). Linear mixed-model analyses demonstrated that TAU+iERT yielded a larger reduction of emotion dysregulation (B = -7.217; p = .046; Cohens d = 0.33), but not depressive symptoms (B = -1.041; p = .607) than TAU.

LIMITATIONS

The study was underpowered to detect small treatment effects. Additionally, uptake of iERT was quite low.

CONCLUSIONS

Although TAU+iERT resulted in a larger decrease of emotion dysregulation than TAU alone, it was not effective in reducing revictimization and depressive symptoms. Patients' revictimization risk substantially decreased during psychotherapy.

Medication non-adherence and self-inflicted violence behaviors among 185,800 patients with schizophrenia in the community: a 12-year cohort study

BACKGROUND

Despite the importance of medication adherence in treatment effectiveness, little is known about the association between medication non-adherence and self-inflicted violence behaviors. We aimed to assess whether medication non-adherence increased the risk of self-inflicted violence behaviors among schizophrenics in communities (hypothesis 1) and whether the dose-response relationship existed (hypothesis 2).

METHODS

This 12-year cohort study in western China recruited 292,667 community-dwelling schizophrenics. The proportion of regular medication (PRM) was calculated by dividing the time of "regular adherence" by the total time of antipsychotic treatment during follow-up period as an indicator of medication adherence. For hypothesis 1, medication adherence was designated as a binary variable with a threshold of 0.8 (PRM); for hypothesis 2, medication adherence was specified as five-category and continuous variables, respectively. Inverse probability weighting and mixed effects Cox proportional hazards models were conducted for confounders control and survival analyses.

RESULTS

One hundred eighty-five thousand eight hundred participants were eligible for the final analyses, with a mean age of 47.49 years (SD 14.55 years), of whom 53.6% were female. For hypothesis 1, the medication non-adherence group (PRM < 0.8) had a lower risk of suicide (HR, 0.527, 95% CI, 0.447-0.620), an increased risk of NSSI (HR, 1.229, 95% CI, 1.088-1.388), and non-significant risk of attempted suicide compared with adherence group (PRM ≥ 0.8). For hypothesis 2, the lowest medication adherence (PRM < 0.2) was associated with increased risks of suicide attempt (HR, 1.614, 95% CI, 1.412-1.845), NSSI (HR, 1.873, 95% CI, 1.649-2.126), and a decreased risk of suicide (HR, 0.593, 95% CI, 0.490-0.719). The other non-adherence groups had lower risks for all three self-inflicted violence behaviors. The associations between medication adherence in continuous-variable and three outcomes were consistent with the categorical medication adherence results.

CONCLUSIONS

Almost no medication taken as prescribed was associated with an increased risk of suicide attempt and NSSI. However, medication adherence did not appear to prevent completed suicide. Besides, patients with moderate adherence had a lower incidence of suicide attempt and NSSI. These findings highlight the need for a more detailed portrayal of medication adherence and the need to be vigilant for suicide intent in schizophrenics with good medication adherence who may be overlooked previously.

Violent victimization and revictimization in patients with depressive disorders: context characteristics, disclosure rates, and gender differences

BACKGROUND

Depressed patients are prone to violent victimization, and patients who were victimized once are at increased risk to fall victim to violence again. However, knowledge on the context of victimization in depressed patients is lacking, and research identifying targets for prevention is urgently needed.

METHODS

This cross-sectional study explored context characteristics, disclosure rates and gender differences regarding violent victimization in 153 recently victimized depressed patients. Additionally, 12-month prevalence rates of repeat threat, physical assault, and sexual assault were examined, and gender differences were investigated using t-tests, Chi-square tests, and Fisher's exact tests. Furthermore, logistic regression analyses were used to identify factors associated with repeat victimization.

RESULTS

Overall, depressed men were most often victimized by a stranger in public, and women by their partner or ex-partner at home. Regarding sexual assault, no gender differences could be examined. Patients were sexually assaulted most often by an acquaintance (50.0%) or stranger (27.8%). In all patients, the most recent incidents of threat (67.6%) and physical assault (80.0%) were often preceded by a conflict, and only a minority had been intoxicated prior to the assault. Notably, less than half of patients had disclosed their recent experience of threat (40.6%) and physical assault (47.1%) to their mental health caregiver. For sexual assault, this was only 20%. Less than one third of patients had reported their recent experience of threat (27.9%), physical assault (30.0%) and sexual assault (11.1%) to the police. 48.4% of patients had been victimized repeatedly in the past year, with no gender differences found. Only depressive symptoms and unemployment were univariately associated with repeat victimization, but not in the multiple model.

CONCLUSIONS

The high prevalence of repeat victimization in depressed patients and their low disclosure rates stress the need to implement routine enquiry of victimization in mental health care, and to develop preventive interventions accounting for specific needs of men and women.

Patient’s Experiences of Violence as Perpetrator: A Qualitative Study from Patients with Schizophrenia in Indonesia

BACKGROUND: Individuals with schizophrenia are at an increased risk for violence – limited study on exploring the experience of violence in patients with schizophrenia as a perpetrator. AIM: This research aimed to investigate the perception of violence as a perpetrator in Indonesia in patients with schizophrenia. METHODS: This study used phenomenology using a purposive sampling technique. A total of 40 patients were from the psychiatric ward of significant mental hospitals in West Java, Indonesia. The inclusion criteria for patients were the following: Age over 18 years old confirmed diagnosis with schizophrenia. Focus group discussion of patients comprised four groups. Each group consisted of tens of patients. RESULTS: The patient’s experiences as a perpetrator were categorized into six subthemes: Committing physical violence to family, quarreling with family, verbal abuse to family, a perpetrator of verbal violence to neighbors, expression of anger to object, and physical violence to nurse. CONCLUSION: The patient’s experiences of violence were not linear, but rather it was a complex experience of being a perpetrator, yet at the same time as of perpetrator violence. A staff training program to reduce patient violence is needed.

Serious physical assault and subsequent risk for rehospitalization in individuals with severe mental illness: a nationwide, register-based retrospective cohort study

BACKGROUND

Victimization is associated with worse social and clinical outcomes of individuals with severe mental illness (SMI). A relapse of SMI may be one of the clinical consequences of assaultive trauma. As far as we know, there is no published study that analyzes nationwide health registers to assess the risk of SMI rehospitalization following assault.

AIM

We aimed to assess whether exposure to assault is associated with an increased risk of psychiatric hospitalization in those with SMI.

METHODS

We utilized data from the Czech nationwide registers of all-cause hospitalizations and all-cause deaths. We defined exposed individuals as those discharged from a hospitalization for SMI between 2002 and 2007, and hospitalized for serious injuries sustained in an assault in the subsequent 7 years. For each assaulted individual, we randomly selected five counterparts, matched on SMI diagnosis, age and sex, who were not assaulted in the examined time period. We used mixed effect logistic regression to assess the effect of assault on the risk of SMI rehospitalization within the following 6 months. We fitted unadjusted models and models adjusted for the number of previous SMI hospitalizations and drug use disorders.

RESULTS

The sample consisted of 248 exposed and 1 240 unexposed individuals. In the unadjusted model, assaulted individuals were almost four times more likely to be rehospitalized than their non-assaulted counterparts (odds ratio (OR) = 3.96; 95% CI 2.75; 5.71). After adjusting for all covariates, the OR remained threefold higher (OR = 3.07; 95% CI 2.10; 4.49).

CONCLUSION

People with a history of SMI hospitalization were approximately three times more likely to be rehospitalized for SMI within 6 months after an assault than their non-assaulted SMI counterparts. Soon after a person with SMI is physically assaulted, there should be a psychiatric evaluation and a close follow-up.

The Effect of Child Sexual Abuse on Social Functioning in Schizophrenia Spectrum Disorders

The objective of this study was to explore social functioning in schizophrenic patients who have suffered child sexual abuse (CSA) in comparison with those who have not suffered from it in a Spanish sample of 50 patients with schizophrenia or schizoaffective disorder. The Quality of Life (QOL) Scale, the Childhood Trauma Questionnaire (CTQ-SF), and the NEO Five Factor Inventory (NEO-FFI) were administered in this study. We found a CSA prevalence of 22% in our sample. Results showed that QOL global scores reduced by 9.34% at a statistically significant level (p = .037) in sexually abused patients in comparison with those who did not report experiencing sexual abuse. Regression analysis in the QOL scales showed no differences in intrapsychic foundation scores or in the social relations scale. Scores in the instrumental role scale were reduced by 4.42 points in patients with CSA (p = .009). Neither neuroticism nor extraversion results differ between the trauma group and those who did not suffer trauma. Clinical implications of these results are discussed.

Mental Health and Victimization: Does Risky Lifestyle Matter?

Research shows that individuals with mental health problems are at an increased risk of victimization compared with individuals without such problems, and certain mental health problems are linked with particular types of victimization. Although most research has not used theory to guide why these differential risks exist, researchers have begun to theorize the reasons why individuals with mental health problems experience victimization. In line with these recent inquiries, the present study uses a Lifestyle/Routine Activities perspective to examine the victimization of people with mental health problems. Further, different types of mental health problems are explored for their potential links to victimization. Risky lifestyle factors are also explored for their potential mediating role in the link between mental health and victimization. A path analysis is conducted with data from the National Longitudinal Study of Adolescent to Adult Health (Add Health). Results suggest that different mental health problems have differing links to victimization types, and lifestyle factors mediate the link for some forms of victimization. The findings imply that certain lifestyle factors explain victimization risk among people with mental health problems, but these individuals may also have unique risk factors related to mental health. Policy implications and directions for future research are discussed.

Do community mental health teams caring for severely mentally ill patients adjust treatments and services based on patients’ antisocial or criminal behaviours?

Background

Antisocial behaviour is common among patients with severe mental illness (SMI) requiring hospitalisation.

Aim

To determine whether differential treatments and services are provided to patients with SMI who engage in antisocial behaviour.

Method

A random sample of 161 inpatients with SMI were recruited from general adult wards and assessed at baseline and two years later. Information on symptoms, aggressive behaviour, substance misuse, and service use was obtained from patients and clinical files.

Results

Past antisocial behaviours were not associated with type or intensity of treatments and services. Severity of positive symptoms, aggressive behaviour, and illicit drug use were positively associated with the frequency of CMHT contact, but not with the type of CMHT, type of medication, or other treatments and benefits.

Conclusions

While the frequency of meetings with CMHTs increased with the severity of antisocial behaviours, no specific treatments were provided to patients with SMI engaging in antisocial behaviours.

Transition Experiences Following Psychiatric Hospitalization: A systematic Review of the Literature

The period immediately following discharge after inpatient stay for mental illness has been found to be the time of greatest risk for adverse outcomes (e.g., rehospitalization, relapse, suicide). However, the experiences of patients as they transition from the hospital to the community are not well understood. The purpose of the present review was to systematically search and synthesize the literature examining the transition experiences of individuals following inpatient psychiatric stay. A systematic search was conducted for studies examining the experiences of patients as they transition back into their communities, using qualitative or quantitative methods. Qualitative articles were analyzed using thematic content analysis. Quantitative articles were extracted and summarized. The search identified 1614 abstracts, of which 27 (18 qualitative; 9 quantitative) were included in the review. The results of the analysis identified themes necessary for transition including safety, supported autonomy, and the opportunity to engage in a number of reintegration activities. A number of barriers were found that prevent integration, such as poverty, interpersonal difficulties, and stigma. The results highlight the disconnect that occurs for patients as they transition from hospital, pointing to the need for effective transitional interventions that target these challenges.

Methodological limitations in the measurement and statistical modeling of violence among adults with mental illness

OBJECTIVES

Methodological limitations of extant research hinder the development of effective violence risk screening, assessment, and management strategies for adults with mental illness. This study quantifies the effects of three common limitations: (a) insensitive measurement of violence that results in violence classification with high levels of information bias, (b) use of cross-sectional data, and (c) use of data lacking spatiotemporal contiguity.

METHODS

We utilize secondary data (N = 3,000 participants; N = 10,017 observations) and parametric and nonparametric bootstrap simulation methodologies.

RESULTS

Not utilizing self-reported violence data increases information bias. Furthermore, cross-sectional data that exclude self-reported violence produce biased associations between substance use and psychiatric symptoms and violence. Associations between baseline variables and subsequent violence attenuate over longer time lags and, when paired with high levels of violence information bias, result in fewer significant effects than should be present. Moreover, the true direction of the simulated relationship of some significant effects is reversed.

CONCLUSIONS

Our findings suggest that the validity of conclusions from some extant research on violence among adults with mental illness should be questioned. Efforts are needed to improve both the measurement of violence, through inclusion of self-report, and the statistical modeling of violence, using lagged rather than nonlagged models with improved spatiotemporal contiguity.

Inferior frontal gyrus gray matter volume is associated with aggressive behavior in schizophrenia spectrum disorders

We aimed to assess potential gray matter (GM) alterations for aggressive patterns of behavior in a sample of in- and outpatients with schizophrenia spectrum disorders. Eighty-four patients previously participating in brain volumetric studies were included. Aggression was assessed using the Modified Overt Aggression Scales (MOAS) based upon review of clinical records of the hospital register. Multiple regression analyses for total MOAS and each MOAS subscale separately were conducted correcting for age, sex, history of addiction, chlorpromazine equivalents, illness duration, and total intracranial volume. Significant effects were reported in two cases; the total MOAS scores and MOAS verbal aggression scores were associated with GM volume in left inferior frontal gyrus. From the demographic/clinical characteristics, only the number of episodes correlated with the subscales and the total MOAS scores. Our results highlight the role of GM volume in left inferior frontal gyri in patients with history of aggression. This evidence ties in well with previous data reporting involvement of these regions in response control and semantic networks.

A History of Trauma is Associated with Aggression, Depression, Non-Suicidal Self-Injury Behavior, and Suicide Ideation in First-Episode Psychosis

The association between trauma and psychosis outcomes is well-established, and yet the impact of trauma on comorbid clinical symptoms-such as aggression, non-suicidal self-injury behavior (NSSIB), suicide ideation, and suicide behavior-for those with psychosis is unclear. To effectively treat those with first-episode psychosis (FEP) and a history of trauma, we need to understand the impact of trauma on their whole presentation. FEP participants were recruited from an Early Psychosis Program (N = 187, ages 12-35, 72.2% male). Clinicians gathered history of trauma, aggression, and suicide data, and rated current symptom severity and functioning. Data was coded using clinician rated measures, self-report measures, and retrospective clinical chart review. Regression analyses examined whether trauma was associated with a history of aggression, suicidal ideation, suicide behavior, NSSIB, symptoms, and functioning. Trauma was associated with aggression, aggression severity and type of aggression (aggression towards others). Trauma was also associated with depression severity, suicide ideation, most severe suicide ideation, and NSSIB. Trauma was not associated with suicide behavior, severity of suicide behavior or psychosocial functioning. Integrating trauma treatment into FEP care could reduce rates of depression, aggression, suicide ideation, and NSSIB for those with a history of trauma. To reduce suicide attempt occurrence and improve functioning, more research is needed.

Psychiatric symptoms and risk of victimisation: a population-based study from Southeast London

AimsAlthough violence is a vital public health problem, no prospective studies have tested for subsequent vulnerability to violence, as a victim or witness, in members of the general population with a range of psychiatric symptoms, or evaluated the importance of higher symptom burden on this vulnerability.

METHODS

We used successive waves of a household survey of Southeast London, taken 2 years apart, to test if association exists between psychiatric symptoms (symptoms of psychosis, common mental disorders, post-traumatic stress disorder and personality disorder) and later victimisation, in the form of either witnessing violence or being physically victimised, in weighted logistic regression models. Statistical adjustment was made for prior violence exposure, sociodemographic confounders, substance/alcohol use and violence perpetration. Sensitivity analyses were stratified by violence perpetration, sex and history of mental health service use.

RESULTS

After adjustments, psychiatric symptoms were prospectively associated with reporting any subsequent victimisation (odds ratio (OR) 1.88, 95% confidence interval (CI) 1.25-2.83), a two times greater odds of reporting witnessed violence (OR 2.24, 95% CI 1.33-3.76) and reporting physical victimisation (OR 1.76, 95% CI 1.01-3.06). One more symptom endorsed was accompanied by 47% greater odds of subsequent victimisation (OR 1.47, 95% CI 1.16-1.86). In stratified analyses, statistical associations remained evident in non-perpetrators, and among those without a history of using mental health services, and were similar in magnitude in both men and women.

CONCLUSIONS

Psychiatric symptoms increase liability to victimisation compared with those without psychiatric symptoms, independently of a prior history of violence exposure and irrespective of whether they themselves are perpetrators of violence. Clinicians should be mindful of the impact of psychiatric symptoms on vulnerability to victimisation, including among those with common psychiatric symptoms and among those who are not considered at risk of perpetrating violence.

Violence towards people with mental illness: Assessment, risk factors, and management

AIM

Violence is an important problem for clinicians, for public health, and for victims. Aside from greater risk of perpetrating violence, people with mental illness are also more commonly victimized than the general population. However, guidance on the assessment and management of violent victimization in clinical settings is limited.

METHODS

We carried out a review and consolidation of clinical and research literature on violent victimization in people with mental illness.

RESULTS

Assessment of mental state in someone who has been victimized should evaluate both historical factors (such as pattern, timing, perpetrator characteristics, and contextual factors) and clinical factors (including affective and cognitive changes).

CONCLUSION

Concerted clinical and policy attention to factors that might increase vulnerability, such as alcohol use, lack of support, and the social environment, could improve outcomes.

Risk of Being Subjected to Crime, Including Violent Crime, After Onset of Mental Illness: A Danish National Registry Study Using Police Data

IMPORTANCE

People with mental illness are more likely to have contact with the criminal justice system, but research to date has focused on risk of offense perpetration, while less is known about risk of being subjected to crime and violence.

OBJECTIVES

To establish the incidence of being subjected to all types of criminal offenses, and by violent crimes separately, after onset of mental illness across the full diagnostic spectrum compared with those in the population without mental illness.

DESIGN, SETTING, AND PARTICIPANTS

This investigation was a longitudinal national cohort study using register data in Denmark. Participants were a cohort of more than 2 million persons born between 1965 and 1998 and followed up from 2001 or from their 15th birthday until December 31, 2013. Analysis was undertaken from November 2016 until February 2018.

EXPOSURES

Cohort members were followed up for onset of mental illness, recorded as first contact with outpatient or inpatient mental health services. Diagnoses across the full spectrum of psychiatric diagnoses were considered separately for men and women.

MAIN OUTCOMES AND MEASURES

Incidence rate ratios (IRRs) were estimated for first subjection to crime event (any crime and violent crime) reported to police after onset of mental illness. The IRRs were adjusted for cohort member's own criminal offending, in addition to several sociodemographic factors.

RESULTS

In a total cohort of 2 058 063 (48.7% male; 51.3% female), the adjusted IRRs for being subjected to crime associated with any mental disorder were 1.49 (95% CI, 1.46-1.51) for men and 1.64 (95% CI, 1.61-1.66) for women. The IRRs were higher for being subjected to violent crime at 1.76 (95% CI, 1.72-1.80) for men and 2.72 (95% CI, 2.65-2.79) for women. The strongest associations were for persons diagnosed as having substance use disorders and personality disorders, but significant risk elevations were found across almost all diagnostic groups examined.

CONCLUSIONS AND RELEVANCE

Onset of mental illness is associated with increased risk of exposure to crime, and violent crime in particular. Elevated risk is not confined to specific diagnostic groups. Women with mental illness are especially vulnerable to being subjected to crime. Individual's own offending accounts for some but not all of the increased vulnerability to being subjected to crime.

Do patients with different psychiatric disorders show altered social decision-making? A systematic review of ultimatum game experiments in clinical populations

BACKGROUND

Impairments in social functioning are a common feature of psychiatric disorders. Game paradigms pose a unique way for studying how people make decisions in interpersonal contexts. In the last decade, researchers have started to use these paradigms to study social decision-making in patients with psychiatric disorders.

PURPOSE

The aim of this systematic literature review is to summarise the currently available evidence on the behaviour of patients with psychiatric disorders in the commonly used Ultimatum Game (UG).

METHOD

A systematic literature search including MEDLINE, PsycINFO, PSYNDEXplus Tests, PSYNDEXPLUS Literature, EBM Reviews-Cochrane Central Register of Controlled Trials, Embase and PASCAL was performed via the Ovid interface.

RESULTS

We found evidence for alterations in UG behaviour for patients with frontotemporal dementia, schizophrenia, affective disorders, alcohol, cocaine, heroin and 3,4-methylenedioxymethamphetamine consumption, alcohol dependence, anxiety disorders, borderline personality disorder, autism, Tourette syndrome and oppositional defiant disorder.

CONCLUSION

There is some evidence that different psychiatric disorders might go along with alterations in social decision-making. However, in general, data are currently limited and studies are hard to compare due to differences in methodologies.

Victimization and posttraumatic stress disorder in homeless women with mental illness are associated with depression, suicide, and quality of life

OBJECTIVE

This study aimed to determine the following: 1) the proportion of women in the homeless population with schizophrenia (SZ) or bipolar disorder (BD), in addition to the trajectory of their homelessness (ie, homelessness history, number of nights spent without home during the 180 past nights) and the characteristics of their illnesses compared to men (ie, illness severity, suicide risk, physical health status, and quality of life [QoL]); 2) whether these women were victimized more frequently than similarly situated men; 3) the impact of victimization on these women in terms of illness severity, suicide risk, physical health status, and QoL; and lastly 4) the differences and overlap of homeless women with SZ and BD.

METHODS

This study employed data at baseline from a multicenter randomized controlled trial conducted in the following four large French cities: Lille, Marseille, Paris, and Toulouse. Mobile mental health outreach teams recruited SZ/BD homeless patients in the street, emergency shelters, hospitals, and jails from August 2011 to April 2014. Evaluations were performed during face-to-face interviews by psychiatrists and research assistants in the offices of mobile mental health outreach teams that were located in the downtown area of each city. The quantitative data were analyzed using descriptive analyses, chi-square and Student's t-tests, generalized estimating equation regression models, and path analysis.

RESULTS

A total of 703 patients were included in this study. The proportion of women in the SZ/BD homeless population was 123/703 (17.5%). In this population, women were more likely than men to declare that they were subjected to physical or sexual assault during the past 6 months, that they had been diagnosed with posttraumatic stress disorder (PTSD), and that they had experienced more severe depressive symptoms. Moreover, these women presented a higher suicide risk, worse physical health status, and lower QoL than similarly situated men. Homeless women with BD were more vulnerable than women with SZ. A path analysis revealed that PTSD and violent victimization might explain the higher levels of depression and suicide risk and the lower levels of physical health status and QoL in homeless women.

CONCLUSION

SZ/BD homeless women experience more PTSD and victimization than men, which are both associated with poor clinical outcomes. These results confirm the vulnerability of homeless women in this high need population and should be considered by public health policy.

Aggressive Behavior Among Persons With Schizophrenia and Those Who Are Developing Schizophrenia: Attempting to Understand the Limited Evidence on Causality

People with, and those who are developing, schizophrenia are at increased risk to engage in aggressive behavior (AGB). Some incidents lead to criminal prosecution. Most people with schizophrenia who commit crimes engage in delinquency and/or AGB prior to first episode. A large proportion of these individuals have a history of childhood conduct disorder (CD) and brain abnormalities suggestive of abnormal neural development distinctive from that of others with schizophrenia. Factors contributing to schizophrenia that is preceded by CD include failing to learn not-to-behave aggressively in early childhood, impairments in understanding emotions in the faces of others, maltreatment, and subsequent re-victimization. Others with no history of antisocial behavior begin engaging in AGB as positive symptoms increase and illness onsets. They too are at elevated risk to be victimized. Specific genetic variants linked to stress regulation in combination with adversity have been associated both with AGB and psychotic symptoms. Effectively treating conduct problems and preventing victimization would reduce AGB by persons with schizophrenia.

Impact of crime victimization on initial presentation to an early intervention for psychosis service and 18-month outcomes

AIM

To investigate the clinical and social correlates of a lifetime history of crime victimization among first-episode psychosis patients at entry to an Early Intervention Service and following 18 months of specialist care.

METHODS

Face-to-face interviews were conducted with 149 individuals who presented to an Early Intervention Service for the first time with psychosis in the London borough of Lambeth, UK. A range of demographic and clinical measures were completed including self-reported history of victimization along with the type of crime and its subjective effect on the patient. Clinical and functional outcomes at 18-month follow up were ascertained from clinical case notes by a psychiatrist.

RESULTS

A large proportion of patients (n = 64, 43%) reported a history of crime victimization. This was associated with significantly higher levels of depression and substance misuse at initial presentation. Being a victim of a crime was not significantly associated with poorer clinical or functional outcomes after 18 months of specialist care. However, non-significant differences were found for those who reported crime victimization in terms of their increased use of illegal substances or having assaulted someone else during the follow-up period.

CONCLUSION

Past experience of being a victim of crime appears to be common in patients presenting for the first time with psychosis and is associated with increased likelihood of comorbidity. Thus, Early Intervention Services should consider screening for past victimization and be prepared to deal with comorbid problems. The impact of crime victimization on clinical and functional outcomes requires investigation over a longer period of time.

New Clinically Relevant Findings about Violence by People with Schizophrenia

OBJECTIVE

To review findings with clinical relevance that add to knowledge about antisocial and aggressive behaviour among persons with schizophrenia.

METHOD

Nonsystematic literature review.

RESULTS

Recent evidence shows that individuals who develop schizophrenia present cognitive deficits, psychotic-like experiences, and internalizing and externalizing problems from childhood onwards. Many of their relatives present not only schizophrenia-related disorders but also antisocial behaviour. While the increased risk of aggressive behaviour among persons with schizophrenia has been robustly established, recent findings show that by first contact with clinical services for psychosis, most people with schizophrenia who will engage in aggressive behaviour may be identified. At first episode, 2 distinct types are distinguishable: those who present a history of antisocial and aggressive behaviour since childhood and those who began engaging in aggressive behaviour as illness onsets. Antipsychotic medications and other treatments shown to be effective for schizophrenia are needed by both types of patients. Additionally, those with a history of antisocial and aggressive behaviour since childhood require cognitive-behavioural programs aimed at reducing these behaviours and promoting prosocial behaviour. Reducing physical victimisation and cannabis use will likely reduce aggressive behaviour. Evidence suggests that threats to hurt others often precede assaults.

CONCLUSIONS

At first contact with services, patients with schizophrenia who have engaged in aggressive behaviour should be identified and treated for schizophrenia and for aggression. Research is needed to identify interactions between genotypes and environmental factors, from conception onwards, that promote and that protect against the development of aggressive behaviour among persons with schizophrenia.

The interplay of psychosis and victimisation across the life course: a prospective study in the general population

PURPOSE

Psychosis has been associated with adult victimisation. However, it remains unclear whether psychosis predicts incident adult victimisation, or whether adult victimisation predicts incident psychosis. Furthermore, a moderating effect of childhood victimisation on the association between psychosis and adult victimisation has not been investigated.

METHODS

The longitudinal association between baseline psychotic experiences and six-year incidence of adult victimisation was assessed in a prospective general population cohort of 6646 adults using logistic regression analysis. The association between baseline adult victimisation and six-year incidence of psychotic experiences was examined as well. Furthermore, the moderating effect of childhood victimisation on these bidirectional associations was analysed.

RESULTS

Psychotic experiences and childhood victimisation were both associated with an increased risk of incident adult victimisation. However, this was through competing pathways, as suggested by a negative interaction between psychotic experiences and childhood victimisation. Baseline adult victimisation and childhood victimisation both independently increased the risk of incident psychotic experiences, but there was no interaction between adult victimisation and childhood victimisation.

CONCLUSIONS

Psychosis and victimisation are interconnected throughout the life course. Childhood victimisation is connected to psychosis through two pathways: one direct and one indirect through adult victimisation. In individuals without childhood victimisation, psychosis and adult victimisation bidirectionally impact on each other.

Anterior cingulate hyperactivations during negative emotion processing among men with schizophrenia and a history of violent behavior

BACKGROUND

Evidence suggests a 2.1-4.6 times increase in the risk of violent behavior in schizophrenia compared to the general population. Current theories propose that the processing of negative emotions is defective in violent individuals and that dysfunctions within the neural circuits involved in emotion processing are implicated in violence. Although schizophrenia patients show enhanced sensitivity to negative stimuli, there are only few functional neuroimaging studies that have examined emotion processing among men with schizophrenia and a history of violence.

OBJECTIVE

The present study aimed to identify the brain regions with greater neurofunctional alterations, as detected by functional magnetic resonance imaging during an emotion processing task, of men with schizophrenia who had engaged in violent behavior compared with those who had not.

METHODS

Sixty men were studied; 20 with schizophrenia and a history of violence, 19 with schizophrenia and no violence, and 21 healthy men were scanned while viewing positive, negative, and neutral images.

RESULTS

Negative images elicited hyperactivations in the anterior cingulate cortex (ACC), left and right lingual gyrus, and the left precentral gyrus in violent men with schizophrenia, compared to nonviolent men with schizophrenia and healthy men. Neutral images elicited hyperactivations in the right and left middle occipital gyrus, left lingual gyrus, and the left fusiform gyrus in violent men with schizophrenia, compared to the other two groups.

DISCUSSION

Violent men with schizophrenia displayed specific increases in ACC in response to negative images. Given the role of the ACC in information integration, these results indicate a specific dysfunction in the processing of negative emotions that may trigger violent behavior in men with schizophrenia.

[Violence by and against people with mental illnesses]

There is robust evidence for an increased risk of violence through people with psychotic disorders. Until recently this was frequently denied to prevent stigmatization. Alcohol and drug abuse equally increases the risk, while appropriate treatment reduces it drastically. Staff in psychiatric hospitals is exposed to an elevated risk of aggressive assaults. A limited number of severely ill and socially disintegrated patients accounts for these incidents, which are often recurrent. Besides patient characteristics, factors such as ward climate, staffing levels, education and attitudes of staff, and physical environment play a major role in aggressive escalations. On the other hand, mentally ill people, particularly women, are themselves at a higher risk of becoming victims of violent and non-violent crime. This also applies after correction for variables such as social status and living environment. Additionally mentally ill people are confronted with violence in the form of coercive interventions legitimised by the state (involuntary admission, involuntary treatment, freedom-restrictive measures such as seclusion or manual/physical restraint). In contrast to other countries in Central and Western Europe, involuntary outpatient treatment has never been legalized in Germany. Efforts to reduce violence and coercion in psychiatric facilities by evidence-based interventions are widespread nowadays, treatment guidelines are available.

Abnormal emotion processing, but intact fairness and intentionality considerations during social decision-making in schizophrenia

Schizophrenia is a severe mental disorder that is highly characterized by social cognitive impairments. Most studies investigating these impairments focus on one specific social domain such as emotion recognition. However, in daily life, processing complex social situations relies on the combination of several social cognitive and affective processes simultaneously rather than one process alone. A modified version of the economically based Ultimatum Game was used to measure the interplay between fairness, intentionality, and emotion considerations during social decision-making. In this task, participants accept or reject fair and unfair monetary offers proposed intentionally or unintentionally by either angry, happy, neutral, or sad proposers. Behavioral data was collected from a group of schizophrenia patients (N = 35) and a group of healthy individuals (N = 30). Like healthy participants, schizophrenia patients differentiated between fair and unfair offers by rejecting unfair offers more compared to fair offers. However, overall patients did reject more fair offers, indicating that their construct of fairness operates within different margins. In both groups, intentional unfair offers were rejected more compared to unintentional ones, indicating a normal integration of intentionality considerations in schizophrenia. Importantly, healthy subjects also differentiated between proposers' emotion when rejecting unfair offers (more rejections from proposers depicting angry faces compared to proposers depicting, happy, neutral, or sad faces). Schizophrenia patients' decision behavior on the other hand, was not affected by the proposers' emotions. The current study thus shows that schizophrenia patients have specific problems with processing and integrating emotional information. Importantly, the finding that patients display normal fairness and intentionality considerations emphasizes preservation of central social cognitive processes in schizophrenia.

Violent and non-violent crime against adults with severe mental illness

BACKGROUND

Little is known about the relative extent of crime against people with severe mental illness (SMI).

AIMS

To assess the prevalence and impact of crime among people with SMI compared with the general population.

METHOD

A total of 361 psychiatric patients were interviewed using the national crime survey questionnaire, and findings compared with those from 3138 general population controls participating in the contemporaneous national crime survey.

RESULTS

Past-year crime was experienced by 40% of patients v. 14% of controls (adjusted odds ratio (OR) = 2.8, 95% CI 2.0-3.8); and violent assaults by 19% of patients v. 3% of controls (adjusted OR = 5.3, 95% CI 3.1-8.8). Women with SMI had four-, ten- and four-fold increases in the odds of experiencing domestic, community and sexual violence, respectively. Victims with SMI were more likely to report psychosocial morbidity following violence than victims from the general population.

CONCLUSIONS

People with SMI are at greatly increased risk of crime and associated morbidity. Violence prevention policies should be particularly focused on people with SMI.

Depressive Symptoms during an Acute Schizophrenic Episode: Frequency and Clinical Correlates

Introduction. Depressive symptoms are common in schizophrenia and are associated with poorer functioning, lower quality of life, and an elevated risk of suicidal behaviour. There are few studies on the occurrence and correlates of these symptoms in acutely ill patients with schizophrenia. Method. 72 acutely ill patients with schizophrenia were assessed for depression using the Calgary Depression Scale for Schizophrenia (CDSS). A cut-off score of ≥6 on the CDSS was used to identify clinically significant depressive symptoms. The relationship between depression and illness variables, including psychotic symptom dimensions as measured by the Positive and Negative Syndrome Scale for Schizophrenia (PANSS), was examined. Results. Eleven (15.3%) patients had clinically significant depressive symptoms. These patients scored higher on the positive and general psychopathology scales of the PANSS and had higher rates of suicidal behavior and poorer functioning. The severity of depressive symptoms was positively correlated with the PANSS positive subscale and negatively correlated with the PANSS negative subscale. Discussion. These findings confirm previous reports that depressive symptoms in active schizophrenia is related to the severity of positive psychotic symptoms and is a risk factor for suicidal behaviour in these patients.

Violent victimization of adult patients with severe mental illness: a systematic review

The aims of this paper are to review data on the prevalence and correlates of violent victimization of persons with severe mental illness, to critically evaluate the literature, and to explore possible approaches for future research. PubMed/MEDLINE and PsycINFO databases were searched using several terms related to severe mental illness in successive combinations with terms describing victimization. The searches identified 34 studies. Nine epidemiological studies indicate that patients with severe mental illness are more likely to be violently victimized than other community members. Young age, comorbid substance use, and homelessness are risk factors for victimization. Victimized patients are more likely to engage in violent behavior than other members of the community. Violent victimization of persons with severe mental illness has long-term adverse consequences for the course of their illness, and further impairs the quality of lives of patients and their families. Victimization of persons with severe mental illness is a serious medical and social problem. Prevention and management of victimization should become a part of routine clinical care for patients with severe mental illness.

Prevalence and impact of childhood abuse in people with a psychotic illness. Data from the second Australian National Survey of Psychosis

Child abuse has been associated with risk of mental illness, including schizophrenia and other psychotic disorders and, among those with mental illness, with a more severe clinical profile. Using an extensively characterised and epidemiologically representative sample of 1825 Australians with a psychotic illness aged 18-64 years and in contact with mental health services, we estimated the proportion of individuals with psychotic disorders who self-reported child abuse and examined its relationship with clinical and other characteristics. The prevalence of child abuse in this nationally representative sample of people with psychotic illness was 30.6%. Women were almost three times more likely to report child abuse compared to males (OR, 2.8, 95% CI 2.3-3.4). When adjusted for age at interview and socio-economic status, there was no significant relationship between self-reported child abuse and type of psychosis or course of illness. Participants with child abuse were significantly more likely to have subjective thought disorder, lifetime suicide attempt and premorbid personality disorder (females only) and anxiety (males only). Our findings demonstrate that child abuse is relatively common across the range of psychotic disorders, with an elevated risk for women in particular, compounding the already high burden associated with psychotic illness. Clinicians need to inquire routinely about child abuse in order to develop appropriate treatment plans tailored to individual needs.

Moral reasoning in schizophrenia: an explorative study into economic decision making

INTRODUCTION

Previous research has suggested that patients with schizophrenia are impaired in appreciating moral values and social norms. Here, we tested the hypothesis--using economic games--that patients with schizophrenia are similar to normals in their ability to recognise unfairness, but perhaps more tolerant towards the acceptance of unfair offers depending on the severity of negative symptoms.

METHODS

Twenty-five patients with schizophrenia played an Ultimatum Game and a Dictator Game with punishment option to examine their ability to appreciate fairness rules and to reinforce equity in comparison to a healthy control group.

RESULTS

As hypothesised, patients accepted significantly more unfair offers than controls. However, rejection rates increased in relation to the unfairness of proposals in both groups. Patients did not differ significantly from controls in the likelihood of punishing unfairness in the Dictator Game or in punishment investment itself.

CONCLUSIONS

Patients with schizophrenia seem to be less sensitive towards unfairness to their own disadvantage, but punish unfairness at a comparable level to controls, which opposes the common view of a general lack of moral value appreciation in schizophrenia.

Violence among people with schizophrenia: phenotypes and neurobiology

People with schizophrenia are at increased risk, as compared to the general population, to acquire convictions for violent crimes and homicide. They also show elevated levels of aggressive behaviour. While psychotic symptoms explain aggressive behaviour that is common during acute episodes, they do not explain such behaviour at other stages of illness or prior to illness onset. Three distinct phenotypes have been identified: individuals with a childhood onset of conduct disorder who display antisocial and aggressive behaviour both before and after schizophrenia onset; individuals with no history of conduct problems who begin engaging in aggressive behaviour as illness onsets; and individuals who after many years of illness engage in a severe physical assault. Little is known about the aetiology of the three types of offenders and about the neural mechanisms that initiate and maintain these behaviours. We hypothesize that schizophrenia preceded by conduct disorder is associated with a combination of genes conferring vulnerability for both disorders and altering the effects of environmental factors on the brain, and thereby, with a distinct pattern of neural development. Some evidence is available to support this hypothesis. By contrast, offending among adults with schizophrenia who have no history of such behaviour prior to illness may result from the changes in the brain that occur as illness onsets, and that are further altered by comorbid conditions such as substance misuse, or by the progressive changes in the brain through adulthood that may result from the illness and from the use of antipsychotic medications.

Victimization of the severely mentally ill in Greece: the extent of the problem

BACKGROUND

In contrast to extensive research on psychiatric patients' dangerousness, very few studies have examined their victimization.

AIM

The aim of our study is to record reported victimization of seriously mentally ill outpatients in Greece and compare them with healthy controls.

METHOD

We interviewed 150 severely mentally ill outpatients and a matched group of healthy controls using a semi-structured interview. This recorded incidents of victimization and perceived discrimination during the previous year. Logistic regression models were used to examine the influence of demographic parameters on both victimization and discrimination.

RESULTS

In this study 59.3% of patients and 46.0 % of controls (p = .02) reported being victims of a criminal act at least once and 52.0% of patients and 24.0 % of controls (p < .001) reported experiencing discrimination during the previous year. Patients, in comparison to controls, were more likely to report being victims of any kind of victimization (OR = 1.85, 95% CI = 1.07-3.21), of assault/threat (OR = 4.62, 95% CI = (2.32-9.19) and of discrimination (OR = 3.34, 95% CI = (2.1-5.62). In addition, patients reported experiencing higher distress in assault/threat crime compared to controls (p = .03).

CONCLUSIONS

Patients with serious mental illness are more likely than the general population to report being victims of criminal acts and experiencing discrimination.

Violence against people with disability in England and Wales: findings from a national cross-sectional survey

Background

The recent World Report on Disability highlighted violence as a leading cause of morbidity among disabled people. However, we know little about the extent to which people with disability experience different violence types, and associated health/economic costs. The recent introduction of disability measures into the England&Wales victimization survey provided an opportunity to address this gap.

Methods and Findings

Analysis of the 2009/10 British Crime Survey (BCS), a nationally representative cross-sectional survey of 44,398 adults living in residential households in England&Wales. Using multivariate logistic regression, we estimated the relative odds of being a victim of past-year violence (physical/sexual domestic or non-domestic violence) in people with disability compared to those without, after adjusting for socio-demographics, behavioural and area confounders. 1256/44398(2.4%) participants had one or more disabilities including mental illness (‘mental illness’) and 7781(13.9%) had one or more disabilities excluding mental illness (‘non-mental disability’). Compared with the non-disabled, those with mental illness had adjusted relative odds (aOR) of 3.0(95% confidence interval (CI) 2.3–3.8) and those with non-mental disability had aOR of 1.8(95% CI: 1.5–2.2) of being a victim of past-year violence (with similar relative odds for domestic and non-domestic violence). Disabled victims were more likely to suffer mental ill health as a result of violence than non-disabled victims. The proportion of violence that could be attributed to the independent effect of disability in the general population was 7.5%(CI 5.7–9.3%), at an estimated cost of £1.51 billion. The main study limitation is the exclusion of institutionalised people with disability.

Conclusions

People with disability are at increased risk of being victims of domestic and non-domestic violence, and of suffering mental ill health when victimized. The related public health and economic burden calls for an urgent assessment of the causes of this violence, and national policies on violence prevention in this vulnerable group.

The role of psychopathic traits and substance abuse in predicting violent victimization in patients with schizophrenia spectrum disorders

We examined the relationship between psychopathic traits and substance abuse and violent victimization in 94 community patients meeting DSM-IV criteria for schizophrenia spectrum disorders in contact with public mental health services in Victoria, Australia. Data on violence and victimization were collated from multiple sources and combined to categorize patients into victims of serious violence (VV; n = 74) and those who were not victims of serious violence (NVV; n = 20) groups. The VV group had higher rates of unemployment and previous violence but did not differ from the NVV on current symptom ratings. The VV group has significantly higher substance abuse and psychopathy scores, but only psychopathy score significantly contributed to the prediction of victimization. All psychopathy facets were reasonably good predictors of victimization status, but the antisocial facet contributed most to the prediction of victimization. A better understanding of the role and contribution of antisocial (particularly psychopathic) traits in violent victimization in mentally ill populations is needed to better inform community management plans.

Factors associated with self-report of sexual violence against men and women with mental disorders in Brazil

OBJECTIVES

Patients with mental illness (PMI) are more vulnerable to sexual violence (SV). This study aimed at assessing factors associated with SV against PMI, stratified by gender in Brazil.

METHODS

Cross-sectional multicenter study with a national sample of 2,475 PMI randomly selected from 26 psychiatric services. Odds ratios were estimated with 95% confidence interval using logistic regression.

RESULTS

A high prevalence of lifetime SV against PMI was observed (19.8%) and it was higher among women (26.6%) than men (12.5%). Among women, episodes of SV were more often caused by intimate partners and in the domestic environment, and among men, by strangers and in the streets. Among women, the following variables were independently associated (p < 0.01) with SV: younger age, living alone, history of homelessness, previous psychiatric hospitalization, lifetime STD diagnosis, early debut of sexual intercourse, irregular condom use, receiving/offering money for sex, and psychiatric diagnosis. Among men, younger age, previous and earlier psychiatric hospitalization, lifetime illegal drug use, receiving/offering money for sex, and psychiatric diagnosis were independently associated with SV.

CONCLUSIONS

The prevalence of SV in the studied population was high, especially among women. Women have more behavior factors associated with SV and they need protection, especially those in isolation and socially deprived. However, men also suffer SV, usually more often during childhood than adulthood and special attention should be given to lifetime illegal drug use and earlier psychiatric hospitalization. Preventive actions beyond mental health are important, such as social and economic actions to improve the living conditions of PMI.

A UK population-based study of the relationship between mental disorder and victimisation

PURPOSE

To establish the prevalence of victimisation in a UK population-based sample and to investigate the association between mental disorder and victimisation in both cross-sectional and prospective manner, whilst adjusting for potential confounds.

METHODS

Data from the National Child Development Study (NCDS) were used to examine criminal victimisation, violent victimisation, and mental disorder at age 46 yerars, and also to measure history of mental disorder, when cohort members were aged 23, 33 and 42 years. Variables considered to be potential confounders or mediators of the association, including socio-economic status, family income, financial strain, education, housing ownership status, heavy drinking and gender, all measured at age 46 years, were considered in multivariate analyses.

RESULTS

The prevalence of criminal victimisation amongst cohort members in the 12 months preceding interview was 15%; 2.2% of the participants reported experiencing violent victimisation in the past year. Mental disorder at age 46 was significantly associated with criminal and violent victimisation, even after adjusting for potential confounds. A prior history of mental disorder was found to be a robust predictor of criminal and violent victimisation.

CONCLUSIONS

This study provides evidence that those with a mental disorder are at elevated risk of victimisation, including violent victimisation. That such an association might reflect an underlying causal relationship is further supported by the confirmation that the association holds true when mental disorder is measured well before the assessment of victimisation risk, and that it persists despite adjustment for a number of potential confounding factors.

Criminally violent victimisation in schizophrenia spectrum disorders: the relationship to symptoms and substance abuse

Background

Violent victimisation among people with major mental illness is well-documented but the risk factors for criminal violent victimisation are not well understood.

Methods

We examined the relationship between illness-related variables, indices of substance abuse and previous history of violence in a sample of 23 male criminally violently victimized and 69 non-criminally violently victimized male patients with DSM-IV-TR diagnoses of schizophrenia and schizoaffective disorder that were resident in the community and in contact with public mental health services in Victoria Australia. Data on criminal victimisation was acquired from the police database.

Results

Demographic, a history of violence or illness-related variables did not distinguish between those had been the victim of a violent crime and those who had not. Our data indicated that drug abuse was a key factor in distinguishing between the groups, but the age of onset of substance abuse was not a significant factor. Scores on measures of drug abuse were modest predictors of criminal victimisation status in our Receiver Operator Characteristic analyses.

Conclusion

Overall, our findings suggest that substance abuse (particularly drug abuse) is a key predictor of violent victimisation based on criminal statistics. The latter has implications for mental health professions involved in the care planning and community management of patients with major mental illness and work points to the importance of substance abuse treatment in the prevention of victimisation as well as violence perpetration.

Victimization in individuals suffering from psychosis: a Swedish cross-sectional study

The aims of the study were to investigate: (1) self-reported adulthood and last-year victimization in male and female outpatients suffering from psychosis; (2) relationships to perpetrators; (3) whether drugs or alcohol were involved in victimization situations; (4) places where victimization occurred. Patients were randomly selected from five outpatient units geared to patients with psychosis; 174 patients participated in a structured face-to-face interview. Experiences of victimization in adulthood were reported by 67%, 33% in the previous year. During adulthood 51% had been physically and 32% sexually victimized and 39% threatened. In the previous year 21% reported threats, 20% physical and 15% sexual victimization. Women reported greater exposure to physical and sexual victimization than men during adulthood and in the previous year. Strangers and acquaintances were mainly reported as perpetrators and half (55%) of those victimized in the previous year stated no involvement of alcohol or drugs. Victimization mainly occurred in the patients' own home (59%), outside downtown (34%), or in others homes (38%). The results of this study give reason to highlight the importance for research and clinical practices to adopt a broad frame of interpretation concerning victimization in patients, covering both individual and environmental factors.

Childhood trauma and psychosis - what is the evidence?

In the last decade, a substantial number of population-based studies have suggested that childhood trauma is a risk factor for psychosis. In several studies, the effects held after adjusting for a wide range of potentially confounding variables, including genetic liability for psychosis. Less is known about the mechanisms underlying the association between childhood trauma and psychosis. Possible pathways include relationships between negative perceptions of the self, negative affect, and psychotic symptoms, as well as biological mechanisms such as dysregulated cortisol and increased sensitivity to stress. Psychotic patients with a history of childhood trauma tend to present with a variety of additional problems, including post-traumatic stress disorder, greater substance abuse, higher levels of depression and anxiety, and more frequent suicide attempts. Initial studies suggest that trauma-specific treatments are as beneficial for these patients as for other diagnostic groups.

Trauma exposure and posttraumatic stress disorder in adults with severe mental illness: a critical review

There is a great deal of research on the prevalence, correlates, and treatment of PTSD in the general population. However, we know very little about the manifestation and consequences of PTSD in more complicated patient populations. The purpose of the current paper is to provide a comprehensive review of PTSD within the context of severe mental illness (SMI; i.e., schizophrenia spectrum disorders, mood disorders). Extant data suggest that trauma and PTSD are highly prevalent among individuals with SMI relative to the general population, and both are associated with adverse clinical functioning and increased healthcare burden. However, trauma and PTSD remain overlooked in this population, with low recognition rates in public-sector settings. Additionally, there are few data on the clinical course and treatment of PTSD among individuals with SMI. Particularly lacking are longitudinal studies, randomized controlled treatment trials, and studies using ethno-racially diverse samples. Furthermore, there is a need to better understand the interplay between trauma, PTSD, and severe forms of mental illness and to further develop and disseminate evidence-based PTSD treatments in this population. The current state of the literature and future directions for practice are discussed.

Gender and violence against people with severe mental illness

Men and women with severe mental illness (SMI) are at significantly increased risk of violent victimisation, but the gender pattern for this has not been systematically examined. In the general population, men are at higher risk of overall and physical victimisation, whilst women are at increased risk of domestic and sexual violence. We re-examined published victimisation studies from a gender perspective, and found that, compared to the general population, women with SMI are at greater excess risk than men, leading to a narrowing in the 'gender gap'. We discuss theoretical explanations for this and implications for prevention and research.

Violence and phases of illness: differential risk and predictors

This study tested the hypothesis that among patients with schizophrenia the risk and correlates of aggressive behavior differ depending on the level of positive symptoms. Two hundred and fifty-one adults with schizophrenia who were living in the community were assessed by psychiatrists using validated instruments. Patients and collaterals reported aggressive behavior. In a final multivariate model, aggressive behavior was significantly and positively associated with childhood conduct disorder, current use of illicit drugs, positive, threat-control-override (TCO), and depression symptoms. While 16% of the patients with two or fewer positive symptoms engaged in aggressive behavior in the previous six months, this was true of 28.4% of those with three or more positive symptoms (X2 (n=251,1)=5.48, P=0.019). Among patients with high positive symptoms, even univariate analyses failed to detect any factors associated with aggressive behavior other than medication non-compliance, typical antipsychotic medication, and clozapine. By contrast, among patients with few positive symptoms, aggressive behavior was associated with TCO and depression symptoms, young age, male sex, the number of childhood conduct disorder symptoms, prior aggressive behavior, and current illicit drug use. In phases of illness characterized by different levels of positive symptoms, the risk of aggressive behavior and the associated factors differ.

Violent victimization of psychiatric patients: a Swedish case-control study

OBJECTIVES

To report the rate of violent victimization of psychiatric patients 1 year before interview and to examine the relative rate in comparison to the general population.

METHOD

Cases were recruited from two public psychiatric hospitals in Stockholm County (n = 390). The controls comprised gender- and age-matched people interviewed in an annual national survey of living conditions (n = 1,170).

RESULTS

Twenty percent of the patients had been victimized during the preceding year. The relative rate was six times higher than that of the controls. Women appeared to be most vulnerable with a tenfold risk increase.

CONCLUSIONS

The findings stress that psychiatric patients are vulnerable to other people's violent behaviour.

Racism, mental illness and social support in the UK

PURPOSE

The difference in risk of mental illness in UK ethnic minorities may be related to a balance between specific risk factors such as racial discrimination and mediating factors such as social support. We investigated whether social support from friends or relatives reduces the cross-sectional association between perceived racism and the risk of mental illness in an ethnic minority group.

METHODS

We conducted secondary analyses of nationally representative community samples of five UK ethnic minority groups (EMPIRIC dataset; n = 4,281) using multiple regression techniques.

RESULTS

We found that the associations between perceived racism, common mental disorder and potentially psychotic symptoms were mainly independent of social support as measured by the number of close persons and their proximity to the individual.

CONCLUSION

Social support when measured in this way does not mediate the associations between perceived racism and mental ill health in this population-based sample.