The major mental disorders and crime: stop debating and start treating and preventing

High Risk, High Dose?-Pharmacotherapeutic Prescription Patterns of Offender and Non-Offender Patients with Schizophrenia Spectrum Disorder

Compared to acute or community settings, forensic psychiatric settings, in general, have been reported to make greater use of antipsychotic polypharmacy and/or high dose pharmacotherapy, including overdosing. However, there is a scarcity of research specifically on offender patients with schizophrenia spectrum disorders (SSD), although they make up a large proportion of forensic psychiatric patients. Our study, therefore, aimed at evaluating prescription patterns in offender patients compared to non-offender patients with SSD. After initial statistical analysis with null-hypothesis significance testing, we evaluated the interplay of the significant variables and ranked them in accordance with their predictive power through application of supervised machine learning algorithms. While offender patients received higher doses of antipsychotics, non-offender patients were more likely to receive polypharmacologic treatment as well as additional antidepressants and benzodiazepines. To the authors' knowledge, this is the first study to evaluate a homogenous group of offender patients with SSD in comparison to non-offender controls regarding patterns of antipsychotic and other psychopharmacologic prescription patterns.

From overkill to beheading: A case report of a schizophrenic matricide

Initial evidence exists on a subtype of matricide committed by subjects suffering from severe mental disorders. Matricide perpetrators often undergo a forensic psychiatric evaluation during the subsequent criminal trial because of supposed legal insanity. The few studies on matricide by mentally disordered perpetrators suggested a possible association between such extreme form of violence and schizophrenia spectrum disorders, especially in case of active delusions or hallucinations.

METHODS

we analyze a case of a young male with a recent diagnosis of psychotic disorder who committed matricide by inflicting multiple injuries and beheading. Data emerging from the forensic pathological analysis of the victim, as well as the forensic psychiatric analysis of the matricide perpetrator are discussed within an interdisciplinary perspective.

RESULTS

the autopsy revealed multiple stab wounds in the regions of the upper limbs, abdomen, chest, and neck, the latter determining beheading. The forensic psychiatric evaluation yielded a diagnosis of schizophrenia and clarified the causal role in the homicidal behavioral of active psychotic symptoms.

CONCLUSION

the specific type of delusional content, and perpetrator-victim relationship might contribute explaining a subtype of extremely violent homicide in recent onset schizophrenia.

Prevalence and Associated Factors of Aggressive Behavior among Patients with Schizophrenia at Ayder Comprehensive Specialized Hospital, Ethiopia

Introduction. Mental illness and aggression are often seen as inextricably linked. There is a growing body of evidence on aggressive behavior towards others by people with schizophrenia. Even though there is no study conducted in this study area, this study will help to identify the factors associated with aggressive behavior to be dealt early and as a base line for further study. Therefore, this study was designed to determine the prevalence of aggressive behavior and associated factors among people with schizophrenia.

Method

An institutional-based cross-sectional study was conducted at Ayder Comprehensive Specialized Hospital from May 6 to 31, 2019, among 403 participants who were selected by a systematic random sampling technique. Data was collected by an interview technique by using the Modified Overt Aggression Scale, entered and analyzed by using EPI-INFO version 3.5.3 and Statistical Package for Social Science version 20, respectively. The association between variables was analyzed using bivariate and multivariate logistic regression analyses, and the level of significance of association was determined at a P value < 0.05.

Results

A total of 403 schizophrenia patients were included making the response rate 95.4%. The prevalence of aggressive behavior was 26.6%. Significant associated factors for aggressive behavior were being male (AOR = 2.61, 95% CI (1.21, 5.61)), unemployment (AOR = 8.03, 95% CI (3.08, 25.95)), previous history of aggression (AOR = 6.22, 95% CI (2.75, 14.10)), psychotic symptoms (AOR = 8.12, 95% CI (3.11, 21.14)), drug nonadherence (AOR = 6.41, 95% CI (3.02, 13.63)), poor social support (AOR = 3.11, 95% CI (1.35, 7.17)), and alcohol use (AOR = 2.40, 95% CI (1.02, 5.66)).

Conclusion

Prevalence of aggressive behavior is high among schizophrenia patients. Professionals have to identify clearly predictors of aggressive behavior giving special emphasis when treating male schizophrenia patients, who are unemployed, lack social support, with previous history of aggression, and alcohol users.

[Frequency and type of offences committed by men with severe mental disorders by age of antisocial behaviors onset]

OBJECTIVE

There are important differences in frequency and type of offence committed by individuals with severe mental disorders (SMD), depending on whether their antisocial behaviors began at an early age or as adults. However, individuals having shown early antisocial behaviors do not form an homogenous group. This study's objective is to test if the antisocial behaviors earliness could explain this heterogeneity.

METHOD

137 men with SMD under 3 separate legal status were recruited. They were distributed in 3 groups according to the antisocial behaviors earliness.

RESULTS

The participants in the childhood group commit more violent offences and more of them present a substance use disorder compared with those in the adult group. A more frequent alcohol use disorder separates the youth group from the adult group. There is no significant difference between the childhood and the youth group, but there are more reported offences in the childhood group.

CONCLUSIONS

Our results suggest that the age of antisocial behaviors onset should be considered in evaluating risk and managing individuals with SMD.

European violence risk and mental disorders (EU-VIORMED): a multi-centre prospective cohort study protocol

BACKGROUND

The link between schizophrenia spectrum disorders (SSD) and violence is a core issue for most forensic psychiatric services. However, the drivers of violence in this population remain unclear, and, to date tools to predict violence risk have a range of limitations. Perhaps because of this uncertainty about the nature of violence risk, treatment programmes and care pathways for mentally disordered offenders vary substantially across the European Union, and differences in legal and policy frameworks are highly relevant.

METHODS

The three-year EU-VIORMED project (Grant Number PP-2-3-2016, November 2017-October 2020) involves forensic centres in Italy, Austria, Germany, Poland, and the U.K. It aims to: (a) identify and compare violence risk factors, clinical needs, and decision making capacity in violent (N = 200, "cases") and nonviolent patients with SSD (N = 200; "controls") using a case-control design; (b) test the predictive validity of the HCR-20v3, OxMIS and FoVOx among cases alone (N = 200), using a prospective cohort study; and (c) compare forensic-psychiatric care pathways across the EU, in a continent wide service mapping study.

DISCUSSION

Data collection started in September 2018 and continues. By September 2019, 333 participants have been enrolled (201 cases and 132 controls were recruited). Experts from 23 countries provided data for the service mapping exercise.

TRIAL REGISTRATION

Retrospectively registered on January 2, 2019 as researchregistry4604 January 2, 2019.

A feasibility study on violence prevention in outpatients with schizophrenia

Patients with schizophrenia have an increased risk of violent behavior, and occupy a large percentage of forensic beds. Most patients in forensic psychiatry have already undergone general psychiatric therapy. This predestinates general psychiatrists to identify those patients presenting such a risk, and to try to intervene so that violence can be prevented. Feasibility study of violence prevention using cognitive-behavioral therapy interventions in male patients with schizophrenia on a general psychiatric ward. Of our patients admitted with schizophrenia, 39.1% had committed violent acts against others; the severity of the act was usually low. The percentage of non-participants was high (83.1%). Study subjects were younger, had not been ill for as long, and were less apt to drop out of the ongoing general psychiatric treatment than the non-participants. Study subjects and non-participants did not differ in the violent act's severity. Our therapy manual proved to be sensible and practical. Those of us attempting to prevent schizophrenic patients from committing violence must deal with individuals who are generally hard to reach. We succeeded in achieving a low drop-out rate after having recruited patients who had displayed a substantial propensity to violence against others.

[Delusional misidentification syndromes: A factor associated with violence? Literature review of case reports]

OBJECTIVES

Delusional misidentification syndromes (DMS) correspond to the delusional belief of misidentification of familiar persons, places or objects and to the conviction that they have been replaced or transformed. Several cases of patients who developed violent behavior while suffering from DMS have been published. This led some authors to consider patients with DMS at risk of violence. However, only a few studies have focused on the potential relationship between violence and DMS. The aim of our study was to explore this relationship with a literature review of published cases of patients having committed violent acts associated to DMS.

METHODS

A systematic literature search was conducted on PubMed up to January 2017 using the following term combination "misidentification" and "violence" Fifteen cases of patients with DMS who had committed violent acts were identified. The data from these descriptions were analyzed and synthetized.

RESULTS

Most of the patients were men with a diagnosis of schizophrenia and Capgras syndrome. Acts of violence were severe with a relatively high number of murders or attempted murders. For half of the patients these violent acts were perpetrated with weapons. Victims were regularly the patient's family members and the assaults were usually not planned. Delusional syndromes often progressed for several years. Importantly, substance abuse, which is known to increase the risk of violence in patients with schizophrenia, was only observed in two patients.

CONCLUSION

DMS are associated with several risk factors of violence, such as a diagnosis of schizophrenia, specific delusions including megalomania, persecution, negative affects and identified targets. Despite this risk for severe violence, there are no existing guidelines on how to assess and treat DMS in schizophrenia. Accordingly, we propose (1) the establishment of formal diagnostic criteria, (2) the development of rigorous research on these syndromes and (3) the integration of DMS in assessment of violence risk in schizophrenic patients.

Method of homicide and severe mental illness: A systematic review

There is limited research that has examined offense characteristics in homicides committed by individuals with mental illness and with differing psychiatric diagnoses. The aim of this systematic review is to synthesize previous findings of studies analyzing homicide behavior by mentally ill individuals, and reporting any associations between mental illness and method of homicide. We searched four databases (MedLine, PsychINFO, Web of Science and Embase), and identified 52 relevant articles for analysis. Of these 52 articles, nine reported specific information on mental illness and method of homicide. Five out of nine articles revealed an association between schizophrenia/delusional disorder and the use of sharp instruments as a method of homicide. Four out of nine studies revealed an association between mood disorders (bipolar disorder/major depression) and strangulation/asphyxiation/suffocation/drowning. Our review confirms consistency across studies reporting a significant association between close contact methods and schizophrenia/mood disorders. Also identified as possible influential factors concerning weapon choice are illness duration, victim characteristics and planning/lack of planning of the homicide. Additionally, studies revealed up to 96% of severely mentally ill offenders experienced psychiatric symptoms at the time of the homicide. Future research may examine the presence of specific psychiatric symptoms when a mentally ill offender commits a homicide and whether these may be more influential in the method of homicide used than the psychiatric diagnosis of the offender.

The evaluation stage of the Hoeven Outcome Monitor (HOM): Towards an evidence based groundwork in forensic mental health

This study examined if a macro-, meso-, and micro outcome measurement instrument that constitutes the evaluation stage of a Dutch forensic psychiatric outcome monitor, the Hoeven Outcome Monitor (HOM), can provide a first step towards a more evidence based groundwork in forensic mental health. General, serious, very serious, special, and tbs meriting recidivism during treatment, after treatment, and overall were charted for forensic psychiatric patients discharged from a Dutch forensic psychiatric centre between 1999 and 2008 (N=164). Re-conviction data were obtained from the official Criminal Records System, and the mean follow-up time was 116.2months. First, the results showed that the macro-measurements provide comparative outcome measures to generate insight into the overall effectiveness of forensic psychiatric treatment. Second, the meso-measurements yielded clinically relevant treatment outcome data for all discharged patients to generate a complete view of treatment effectiveness. Finally, the micro-measurements allowed access to detailed patient and treatment effectiveness assessments that provides the empirical foundation to conduct aetiological research into the prediction and control of high-risk behaviour. Thus, an outcome measurement instrument in line with Evidence Based Medicine and best practice guidelines was designed that provides an empirically sound evaluation framework for treatment effectiveness, and an impetus for the development of effective interventions to generate an evidence based groundwork in forensic mental health.

Methodological development of the Hoeven Outcome Monitor (HOM): A first step towards a more evidence based medicine in forensic mental health

To comply with the need for a more evidence based risk assessment and management in forensic mental health, an outcome monitor is being developed in the Dutch forensic psychiatric centre Van der Hoeven Kliniek in Utrecht, the Hoeven Outcome Monitor (HOM). Conform evidence based medicine (EBM) guidelines, the HOM is subdivided into three consecutive stages, (1) the evaluation stage, (2) the aetiology stage and (3) the implementation stage. In this article an account is provided for the design of the evaluation stage. To account for predicaments in previous research that pertain to a lack of uniformity and disregard of specific context- and patient-related characteristics, a macro-, meso- and micro-treatment evaluation instrument is developed. This instrument provides for the first step to build an evidence base for specific interventions and treatments in forensic psychiatry.

Housing Trajectories of Forensic Psychiatric Patients

The objectives of this study were to describe the disposition and housing trajectories of individuals found Not Criminally Responsible on account of Mental Disorder (NCRMD), and the factors that predict different trajectories. To do so, disposition and housing status were coded for 934 NCRMD patients over a 36-month follow-up period. Sequential data analysis resulted in four distinct trajectories: detention in hospital, conditional discharge in supportive housing, conditional discharge in independent housing, and absolute discharge to unknown housing. The likelihood of a placement in supportive housing compared with detention significantly decreased for individuals with a higher index offense severity. Less restrictive trajectories were significantly predicted by clinical factors. The results revealed little change in the disposition and housing trajectories of NCRMD patients. Furthermore, decisions about disposition and housing placement reflect a knowledge-practice gap between risk factors known to be predictive of community resources use in the forensic population. Copyright © 2016 John Wiley & Sons, Ltd.

Violent behavior of patients living in psychiatric residential facilities: a comparison of male patients with different violence histories

People with severe mental disorders and a history of violence are often seen as a difficult-to-manage segment of the population. In addition, this group is usually characterized by a high risk of crime recidivism, and poor compliance with community and aftercare programs. To investigate a sample of male patients living in Residential Facilities (RFs) with a history of violent behavior against people and to compare their characteristics with those of never-violent residents; to analyze the associations between aggressive behaviors in the last two years and a history of previous violence; and, to assess the predictors of aggressive behaviors. This study is part of a prospective observational cohort study which involved 23 RFs in Northern Italy. A comprehensive set of sociodemographic, clinical, and treatment-related information was gathered, and standardized assessments were administered to each participant. Also a detailed assessment of aggressive behaviors in the past two years was carried out. The study involved 268 males: 81 violent and 187 never-violent. Compared to never-violent patients, violent patients were younger, with a higher proportion of personality disorders, and have displayed an increased number of aggressive behaviors in the last two years. The presence of a history of violent behavior in the past significantly increases the probability of committing aggressive acts in the future.

Criminal recidivism and mortality among patients discharged from a forensic medium secure hospital

BACKGROUND

One of the goals in forensic psychiatric care is to reduce the risk of recidivism, but current knowledge about the general outcome of forensic psychiatric treatment is limited.

AIMS

To analyse the rate of criminal recidivism and mortality after discharge in a sample of patients sentenced to forensic psychiatric treatment in a Swedish county.

METHODS

All offenders in Örebro County, Sweden, sentenced to forensic psychiatric treatment and discharged during 1992-2007 were included: 80 males and eight females. Follow-up data was retrieved from the Swedish National Council for Crime Prevention, the National Cause-of-Death register and clinical files. Mean follow-up time was 9.4 years.

RESULTS

The mean age at discharge was 40 years. Schizophrenia, other psychoses and personality disorders were the most prevalent diagnoses. Thirty-eight percent of those still alive and still living in the country re-offended and were sentenced to a new period of forensic psychiatric treatment or incarceration during follow-up. Four male re-offenders committed serious violent crimes. Substance-related diagnosis was significantly associated with risk of recidivism and after adjustment for diagnoses, age and history of serious violent crime, the Hazard Ratio was 4.04 (95% CI 1.51-10.86, P = 0.006). Of all included patients, 23% had died at the end of follow-up (standardized mortality rate 10.4).

CONCLUSIONS

Since repetition of serious violent crimes was unusual, results indicate a positive development subsequent to treatment for those alive at follow-up.

CLINICAL IMPLICATIONS

The high mortality rate suggests that more attention should be paid in evaluation of the patients' somatic and psychiatric health during and after care in order to prevent premature death.

Prevalence of mental disorder and related treatments in a local jail: a 20-month consecutive case study

Aims – To define the prevalence of mental disorder within an Italian local jail and to describe main psychiatric treatments provided. Methods – Cross-sectional study of consecutive male prisoners referred, over a twenty-month period, for a clinical psychiatric assessment, among population (N=990) of Casa circondariale “Torre del Gallo”, Pavia (I); clinical DSM-IV diagnostic assessment and retrospective analysis of provided psychiatric treatments (i.e. psychiatric visits and pharmacological prescriptions). Results – 191 men (19.3%) had one or more current mental disorders (excluding substance misuse), including 13 (1.3%) psychosis; 53 (5.4%) mood disorder; 24 (2.4%) anxiety disorder; 26 (2.6%) adjustment disorder; 40 (4.1%) personality disorder; 32 (3.2%) personality disorder plus mood disorder; 3 (0.3%) mental retardation. Substance- (N=89, 47%) and HIV-related (N=19, 10%) disorders comorbidity is recognised. Psychiatric visits are mainly provided to psychosis and personality disorder plus mood disorder subgroups. Off-label antipsychotics prescriptions are frequent. Conclusions – The prevalence of mental disorder in this population is higher than US and EU averages, and for particular diagnostic subgroups it could be underestimated. Psychiatric management in prison should be reorganized according to national and European health guidelines.

Schizophrenia disorders, substance abuse and prior offending in a sequential series of 435 homicides

OBJECTIVE

To examine the relationship between committing homicide, the presence of schizophrenia, substance misuse and past criminality.

METHOD

The study employed a data linkage design, using contacts recorded on two statewide databases, one of which recorded public mental health services contacts and the second of which recorded contacts with the police. The estimated rates of schizophrenia disorders, substance abuse and criminal convictions found among a population of 435 homicide offenders were contrasted with estimated rates in two composite comparison samples.

RESULTS

Of the 435 offenders, 38 (8.7%) had been diagnosed with a schizophrenia disorder, which was RR 13.11 (95% CI 9.14-18.80) times more likely than a comparison sample. Rates of known substance abuse between homicide offenders with and without schizophrenia and community-dwelling residents with schizophrenia did not differ significantly. However, these rates were higher than those found in the general community. A similar pattern emerged for comparisons regarding offending histories between these same groups.

CONCLUSION

The association between homicidal violence and having a schizophrenia disorder cannot be explained away simply on the basis of either comorbid substance abuse or prior criminal offending.

Comportamento violento, gênero e psicopatologia

A violência cometida por indivíduos com transtornos mentais graves tem se tornado um foco crescente de interesse entre profissionais de saúde, autoridades policiais e outros segmentos da sociedade. Na população geral, os homens são mais agressivos do que as mulheres. Entretanto, tem sido encontrado que a diferença de gênero em relação ao comportamento violento é menor entre os indivíduos que apresentam transtornos mentais, comparados àqueles que não apresentam estes transtornos.

La prescription de médicaments psychotropes aux personnes incarcérées dans les prisons provinciales du Québec

Dans cet article, les auteurs tentent de mieux cerner la pratique de la prescription de médicaments psychotropes auprès des personnes incarcérées dans les prisons provinciales du Québec. Bien que la prescription de ces médicaments s’avère le « traitement psychiatrique » le plus utilisée, rares sont les études qui portent sur sa prévalence. L’étude porte sur un échantillon de 671 personnes détenues, soit 500 hommes et 171 femmes. Globalement, 40,3 % des incarcérés ont reçu au moins une ordonnance de médicament psychotrope dans la période comprise entre 2002 et 2007. Les résultats démontrent que les femmes sont plus susceptibles d’avoir fait usage de médicaments que les hommes. Les personnes incarcérées ayant reçu au moins une prescription sont en moyenne plus âgés que les autres. Une majorité d’ordonnances a été émise par des omnipraticiens et les cas de polypharmacie sont nombreux. Sur une période de cinq ans, la classe de médicaments la plus prescrite est celle des anxiolytiques/hypnotiques, suivie des antidépresseurs et des antipsychotiques. Les auteurs concluent qu’il faudra analyser davantage les facteurs associés à la prescription de cette classe de médicaments auprès des personnes criminalisées.

Schizophrenia, substance abuse, and violent crime

CONTEXT

Persons with schizophrenia are thought to be at increased risk of committing violent crime 4 to 6 times the level of general population individuals without this disorder. However, risk estimates vary substantially across studies, and considerable uncertainty exists as to what mediates this elevated risk. Despite this uncertainty, current guidelines recommend that violence risk assessment should be conducted for all patients with schizophrenia.

OBJECTIVE

To determine the risk of violent crime among patients diagnosed as having schizophrenia and the role of substance abuse in mediating this risk.

DESIGN, SETTING, AND PARTICIPANTS

Longitudinal designs were used to link data from nationwide Swedish registers of hospital admissions and criminal convictions in 1973-2006. Risk of violent crime in patients after diagnosis of schizophrenia (n = 8003) was compared with that among general population controls (n = 80 025). Potential confounders (age, sex, income, and marital and immigrant status) and mediators (substance abuse comorbidity) were measured at baseline. To study familial confounding, we also investigated risk of violence among unaffected siblings (n = 8123) of patients with schizophrenia. Information on treatment was not available.

MAIN OUTCOME MEASURE

Violent crime (any criminal conviction for homicide, assault, robbery, arson, any sexual offense, illegal threats, or intimidation).

RESULTS

In patients with schizophrenia, 1054 (13.2%) had at least 1 violent offense compared with 4276 (5.3%) of general population controls (adjusted odds ratio [OR], 2.0; 95% confidence interval [CI], 1.8-2.2). The risk was mostly confined to patients with substance abuse comorbidity (of whom 27.6% committed an offense), yielding an increased risk of violent crime among such patients (adjusted OR, 4.4; 95% CI, 3.9-5.0), whereas the risk increase was small in schizophrenia patients without substance abuse comorbidity (8.5% of whom had at least 1 violent offense; adjusted OR, 1.2; 95% CI, 1.1-1.4; P<.001 for interaction). The risk increase among those with substance abuse comorbidity was significantly less pronounced when unaffected siblings were used as controls (28.3% of those with schizophrenia had a violent offense compared with 17.9% of their unaffected siblings; adjusted OR, 1.8; 95% CI, 1.4-2.4; P<.001 for interaction), suggesting significant familial (genetic or early environmental) confounding of the association between schizophrenia and violence.

CONCLUSIONS

Schizophrenia was associated with an increased risk of violent crime in this longitudinal study. This association was attenuated by adjustment for substance abuse, suggesting a mediating effect. The role of risk assessment, management, and treatment in individuals with comorbidity needs further examination.

Co-occurring psychiatric and substance use disorders among male detainees in Italy

This paper presents data on the prevalence of co-occurring substance use and psychiatric disorders among newly imprisoned males in Italy. Interviewers conducted semi-structured clinical interviews with n=302 male detainees seven days after their admission to the prison of Perugia from August 2005 through July 2006. Over half of male detainees (54.3%) had either a substance use disorder or another psychiatric disorder. One of every five detainees (20.9%) had comorbid substance use and psychiatric disorders. Compared to detainees with psychiatric disorder only, substance use disorder only, or no disorder, detainees with comorbid substance use and psychiatric disorders were significantly more likely to have severe impairment in the areas of employment, substance abuse, family and social functioning, and psychiatric symptoms. Findings underscore the need for careful diagnostic screening at intake, access to treatment during detention, and an effective transition to services at the time of release.

Penrose's law revisited: the relationship between mental institution beds, prison population and crime rate

In 1939, Lionel Penrose published a cross-sectional study from 18 European countries, including the Nordic, in which he demonstrated an inverse relationship between the number of mental hospital beds and the number of prisoners. He also found strong negative correlations between the number of mental hospital beds and the number of deaths attributed to murder. He argued that by increasing the number of mental institution beds, a society could reduce serious crimes and imprisonment rates. The aim of the study was to test Penrose's theories longitudinally by monitoring the capacity of all psychiatric institutions and prisons in a society over time. From official statistics, we collected and systematized all relevant information regarding the number of mental institution beds and prisoners in Norway during the years 1930-2004, along with major crime statistics for the same period. During the years 1930-59, there was a 2% population-adjusted increase in mental institution beds and a 30% decrease in the prison population. During 1960-2004, there was a 74% population-adjusted decrease in mental institution beds and a 52% increase in the prison population. The same period saw a 500% increase in overall crime and a 900% increase in violent crimes, with a concurrent 94% increase in the size of the country's police force. Penrose's law proved remarkably robust in the longitudinal perspective. As opposed to Penrose, however, we argue that the rise in crime rates only to a very limited extent can be attributed to mental health de-institutionalization.

Psychiatric use and utility of divalproex sodium in Connecticut prisons

Divalproex sodium (DVX) is used in correctional settings to treat impulsive aggression and mood lability in patients without comorbid bipolar disorder. This review of DVX use in the Connecticut Department of Correction examined the psychiatric diagnostic impression of patients prescribed DVX, the doses used, and the symptomatic and functional change over time. Clinical charts of 168 offenders treated with DVX for one or more months were randomly selected for clinical outcome review and were divided into subgroups based on clinical impression for DVX prescription. In participants without bipolar disorder (44.6%), DVX was used to target impulsivity (14.3%) and mood lability (17.3%). Clinical improvement was noted in bipolar and nonbipolar groups (p < .001). The impulsive/aggressive subgroup was the only nonbipolar subgroup in which DVX yielded clinical benefit. This symptom-driven use of DVX is associated with clinical improvement when impulsive aggression is the target symptom.

Aspectos psicopatológicos e forenses de mulheres homicidas com diagnóstico de transtornos psicóticos primários: estudo de série de casos

OBJETIVO: Avaliar amostra de todas as mulheres com diagnóstico de transtorno psicótico primário que receberam medida de segurança e estavam em hospital de custódia e tratamento psiquiátrico em regime de internação (n = 8), em virtude de homicídio ou tentativa de homicídio (artigo 121 do Código Penal Brasileiro). MÉTODOS: Trata-se de um estudo de série de casos. Foi realizado o levantamento retrospectivo de dados por meio de registros periciais e pareceres de equipes de assistência. O diagnóstico psiquiátrico final foi realizado com base na entrevista psiquiátrica e observação dos registros, utilizando-se os critérios diagnósticos do DSM-IV-TR. Houve aplicação de questionário padronizado e escala das síndromes positiva e negativa (PANSS). RESULTADOS: Sete pacientes receberam diagnóstico de esquizofrenia e uma de transtorno esquizoafetivo. A maioria das vítimas (n = 6, 60%) era membro familiar das pacientes. Foi encontrado que 37,5% (n = 3) das pacientes tinham história prévia de comportamento violento. De acordo com a avaliação da perícia psiquiátrica inicial, cinco (62,5%) pacientes da amostra total apresentavam sintomatologia psicótica no momento desta avaliação. As alucinações auditivas foram os sintomas psicóticos mais comuns. CONCLUSÃO: O estudo de fatores motivadores do comportamento homicida pode fornecer conhecimentos para o estabelecimento de intervenções terapêuticas em mulheres com transtornos mentais que apresentem risco para este ou outros comportamentos violentos.

'Crowded suburbs' and 'killer cities': a brief review of the relationship between urban environments and mental health

Most of the world's population now lives in cities, with 90% of Australians living in urban settlements of more than 10 000 people. Urban environments help shape population health, particularly among disadvantaged people, where poor health is concentrated. A growing body of research has focussed on the association between cities and mental health. Three hypotheses have been proposed to explain this association: psychosocial stressors; concentrated disadvantage; and social drift. It remains unclear, however, how the characteristics of urban environments are related to each other and to mental health, and what might be the pathways underpinning the experience of different individuals. With one in five Australian adults meeting the diagnostic criteria for a mental disorder each year, investigation of the relationship between urban environments and mental health is urgently needed. This paper briefly reviews recent studies linking disadvantaged urban environments with mental health and proposes a hypothetical model to help guide future research.

Legal frameworks and key concepts regulating diversion and treatment of mentally disordered offenders in european union member states

Background

There is only limited research on the various legal regulations governing assessment, placement and treatment of mentally ill offenders in European Union member states (EU-member states).

Aims

To provide a structured description and cross-boundary comparison of legal frameworks regulating diversion and treatment of mentally disordered offenders in EU-member states before the extension in May 2004. A special focus is on the concept of criminal responsibility.

Method

information on legislation and practice concerning the assessment, placement and treatment of mentally ill offenders was gathered by means of a detailed, structured questionnaire which was filled in by national experts.

Results

The legal regulations relevant for forensic psychiatry in EU-member states are outlined. Definitions of mental disorders given within these acts are introduced and compared with ICD-10 diagnoses. Finally the application of the concept of criminal responsibility by the law and in routine practice is presented.

Conclusion

Legal frameworks for the processing and placement of mentally disordered offenders varied markedly across EU-member states. Since May 2004 the European Union has expanded to 25 member states and in January 2007 it will reach 27. With increasing mobility across Europe, the need for increasing trans-national co-operation is becoming apparent in which great variation in legal tradition pertains.

Are violence risk assessment tools clinically useful?

Despite increasing concerns regarding the prevalence of violent behaviour in mainstream mental health settings, the impressive body of forensic research on violence risk assessment has thus far had only limited impact on front-line general mental health practice. The common objection raised by clinicians that risk assessment tools lack utility for clinical practice may contribute to this. The present paper argues that this objection, although understandable, is misplaced. Usage of appropriate, validated risk assessment tools can augment standard clinical approaches in a number of ways. Some of their advantages derive simply from having a well-structured approach, others from consideration of specific kinds of risk factors: 'static' and 'dynamic'. The inappropriate use of tools without a firm evidence base, however, is unlikely to enhance clinical practice significantly.

Balancing autonomy and risk: a failure of nerve in England and Wales?

Specialised mental health legislation typically provides for the hospitalisation and treatment of those with mental disorders in the absence of their consent. The article examines the possible justifications for the existence of these special powers and argues that two of the most common justifications, the protection of the patient and the protection of others, do discriminate against those with a mental, as opposed to a physical, disorder. The relationship between mental health and mental capacity, or guardianship, legislation is then considered and possible ways forward are discussed with particular reference to the current reform debate in England and Wales.

Understanding the relationship between mental disorder and violence: the need for a criminological perspective

This paper offers a criminologically informed framework to guide research on the relationship between mental disorder and violence. Criminological theories examined include social learning, social stress, social control, rational choice, and social disorganization. In addition, the "criminal careers" and "local life circumstance" methodologies are reviewed. It is argued that adopting a criminologically informed framework that takes into account within-person changes over time will contribute greatly to our understanding of the factors that affect violence among people with mental disorder living in the community, and enhance the capacity of research to support effective evidenced-based case management programs aimed at reducing violence.

Relação entre homicídio e transtornos mentais

OBJETIVO: Diversos estudos encontraram uma relação entre transtornos mentais graves e violência. Uma das abordagens de estudo deste tema são as investigações com criminosos homicidas. O objetivo do presente artigo foi investigar a associação entre homicídio e transtornos mentais. MÉTODO: Foi realizada uma revisão da literatura, através das seguintes bases de dados: Medline, Scientific Eletronic Library Online e Lilacs. No sistema Medline também foi pesquisada a seção de artigos relacionados. RESULTADOS: Embora exista uma associação entre transtornos mentais e homicídio, não está claro porque alguns pacientes comportam-se de forma violenta e outros não. Transtornos relacionados ao uso de álcool/drogas e transtornos de personalidade comórbidos e falta de aderência ao tratamento podem aumentar este risco. CONCLUSÕES: É justificável a identificação de pessoas com risco elevado de comportamento violento e oferta de tratamento em serviços de saúde mental para as mesmas. Estes serviços deveriam prevenir a perda de contato e não-colaboração com o tratamento que freqüentemente precedem o homicídio perpetrado por pessoas com transtornos mentais graves. É de fundamental importância que a sociedade e as autoridades governamentais diminuam as barreiras de acesso ao tratamento psiquiátrico e psicossocial.

Putting community risk in perspective: a look at correlations, causes and controls

Much research, but not all, appears to show that persons with severe mental illness are more dangerous and violent than others; but it is misleading and feeds the stigma cannon. This paper critically reviews reported correlations between severe mental illness and violence, examines their statistical confounds, highlights studies which seek causal mechanisms explaining the associations, points to what those causal mechanisms tell us about controlling risk in the community, and reviews legal attempts to control community risk in light of those causal mechanisms.

The need for the development and evaluation of preventive psychosocial forensic interventions in mainstream adult community mental health services

OBJECTIVE

This paper provides a selective review of forensic research with the aim of making recommendations for the development and evaluation of psychosocial interventions for the mainstream community mental health setting to address the needs of patients with a history of offending.

CONCLUSION

Mainstream community mental health services can be guided by existing findings in the design of psychosocial intervention and prevention programmes. There is growing need to develop and evaluate such interventions.

Violent behaviour in schizophrenia. Retrospective study of four independent samples from Prague, 1949 to 2000

BACKGROUND

A number of studies have reported increased violence in patients with schizophrenia.

AIMS

To determine the prevalence of violence among those with schizophrenia in samples from 1949, 1969, 1989 and 2000 in Prague (Czech Republic) and to examine trends in this behaviour.

METHOD

Records from 404 patients meeting DSM-IV criteria for schizophrenia were screened for violence (defined as 3 points on the Modified Overt Aggression Scale) from the first observed psychotic symptoms until the time of latest available information.

RESULTS

Logistic regression revealed a marginally significant increase in violence only in the 2000 cohort. Overall, violence was associated with schizophrenia in 41.8% of men and 32.7% of women, with no association between substance misuse and violence.

CONCLUSIONS

The violence rate found in our sample is expected to remain stable over time under stable conditions. Substance misuse is not the leading cause of violence among those with schizophrenia.

Mental health in prison populations. A review--with special emphasis on a study of Danish prisoners on remand

OBJECTIVE

To review the literature on mental health and psychiatric morbidity in prison populations and relate findings to a Danish study on remand prisoners.

METHOD

The literature is reviewed and subdivided in the following section: validity of psychometrics in prison populations, prevalence of psychiatric disorders prior to imprisonment, incidence of psychiatric disorders during imprisonment, psychopathy related to psychiatric comorbidity, dependence syndromes with special emphasis on different administrations of heroin use (smoke vs. injection). The results are compared with a longitudinal Danish study on remand prisoners in either solitary confinement (SC) or non-SC.

RESULTS

Many factors must be taken into consideration when dealing with prisoners and mental health, e.g. international differences, the prison setting, demographics and methodological issues. The prison populations in general are increasing worldwide. Psychometrics may perform differently in prison populations compared with general populations with the General Health Questionnaire-28 having a low validity in remand prisoners. Psychiatric morbidity including schizophrenia is higher and perhaps increasing in prison populations compared with general populations with dependence syndromes being the most frequent disorders. The early phase of imprisonment is a vulnerable period with a moderately high incidence of adjustment disorders and twice the incidence in SC compared with non-SC. Prevalence of psychopathy is lower in European than North American prisons. Medium to high scores of psychopathy is related to higher psychiatric comorbidity. Opioid dependence is the most frequent drug disorder with subjects using injection representing a more dysfunctional group than subjects using smoke administration. Many mentally ill prisoners remain undetected and undertreated.

CONCLUSION

There is a growing population of mentally ill prisoners being insufficiently detected and treated.