A multinational case-control study comparing forensic and non-forensic patients with schizophrenia spectrum disorders: the EU-VIORMED project

Homicide perpetrators with psychotic illness found not criminally responsible in Turkiye and Russia: An international comparison

OBJECTIVE

The primary objective was to conduct a comparative analysis of homicide cases and their perpetrators with psychotic illnesses in samples from Turkiye and Russia to elucidate contextual similarities and differences, and providing novel perspectives to enhance international research in this field.

METHOD

This cross-national retrospective study, conducted at forensic psychiatric centers in Istanbul, Turkiye, and Chuvashia, Russia, involved individuals with psychotic illnesses (ICD-10 F20-F29) who were deemed criminally non-responsible for index homicide offenses between December 2012 and December 2022. The sample included 92 Turkish patients and 29 Russian patients who were compared for background, clinical characteristics, and each homicidal act.

RESULTS

Binary analyses revealed that Russian subjects were more educated, had more lifetime suicide attempts, longer illness duration, had acquaintances as victims more frequently, higher rates of blunt traumatic homicides, higher rates of intoxication with alcohol or substances, and lower rates of experiencing delusions at the time of the index homicide compared to their Turkish counterparts. Multivariate analyses indicated that more years of education, a greater frequency of lifetime suicide attempts, higher prevalence of intoxication and a lower rate of delusions at the time of the homicide were associated with belonging to the Russian group.

CONCLUSION

Despite several similarities, the remarkable differences between the two samples underscore the importance of international research in enhancing our understanding of mental health, homicidal offense and offender characteristics in the sociocultural context.

Mentalizing mediates the relationship between psychopathy and premeditated criminal offending in schizophrenia: a 6-year follow-up study

PURPOSE

Research has shown that schizophrenia augments the risk for criminal behaviour and variables both defining- and related to schizophrenia, increase criminal offending. Premeditated criminal offending is considered a severe form of criminal offending, however, very little is known about what predicts future premeditated criminal offending in schizophrenia.

METHOD AND MATERIALS

In this 6-year follow-up study we explored which factors underlie future premeditated criminal behaviour in a sample of patients diagnosed with schizophrenia (N = 116). We also investigated if a specific mentalizing profile underlie part of the variance of premeditated criminal offending.

RESULTS

Results showed that psychopathy underlie future premeditated crime in schizophrenia, and that a specific mentalizing profile, comprised of a dysfunctional emotional and intact cognitive mentalizing profile in relation to others, mediated parts of the relation between psychopathy and premeditated criminal offending. Finally, our results indicated that patients with schizophrenia with a specific mentalizing profile (see above) engaged in premeditated criminal behaviour earlier during the 6-year follow-up period compared to patients with other mentalizing profiles.

CONCLUSIONS

Our findings suggest that mentalization should carefully be inspected in patients with schizophrenia in relation to future premeditated offending.

Difference between forensic patients with schizophrenia spectrum disorders in Italy and other European countries: Results of the EU-VIORMED project

BACKGROUND

There has been a substantial change in the law on the provision of secure health services for offender-patients in Italy, a country currently with the lowest general psychiatry bed availability per head of the population in Europe, raising questions about possible differences in offender-patient admissions between European countries.

AIMS

In this multicentre case-control study, our aim was to compare the socio-demographic, clinical and criminological characteristics of a sample of Italian forensic in-patients with schizophrenia or similar psychosis with patients in a similar diagnostic range in specialist in-patient services elsewhere in Europe.

METHODS

Secure hospital unit in-patients with psychosis were recruited across five European countries (Italy, Austria, Germany, Poland and England). Consenting patients were interviewed by researchers and assessed using a multidimensional standardised process. Within country similarities between Austria, Germany, Poland and England were confirmed.

RESULTS

Overall, 39 Italian participants had had fewer years of education than the 182 patients in the other countries and were less likely to have ever had skilled or professional employment. The Italian patients had been older at first contact with any mental health services than the other Europeans. Diagnosed comorbidity rates were similar, but the Italian group reported higher levels of disability. Although the other European forensic patients were more likely to be undergoing treatment at the time of their index offence, they were also more likely to have been poorly compliant with treatment. The rate of suicide-related behaviours was significantly lower among the Italian patients than among the others.

CONCLUSIONS

Notwithstanding similar diagnoses, important differences emerged between patients in Italian forensic mental health resident services and those in four other European countries, some possibly reflecting less access to earlier relevant services in Italy. Others, including lower disability ratings among the Italian patients and a lower rate of suicide-related behaviours, may indicate that the Italian reforms carry benefits. This is worthy of further evaluation.

The HARM models: Predicting longitudinal physical aggression in patients with schizophrenia at an individual level

The prediction and prevention of aggression in individuals with schizophrenia remains a top priority within forensic psychiatric settings. While risk assessment methods are well rooted in forensic psychiatry, there are no available tools to predict longitudinal physical aggression in patients with schizophrenia within forensic settings at an individual level. In the present study, we used evidence-based risk and protective factors, as well as variables related to course of treatment assessed at baseline, to predict prospective incidents of physical aggression (4-month, 12-month, and 18-month follow-up) among 151 patients with schizophrenia within the forensic mental healthcare system. Across our HARM models, the balanced accuracy (sensitivity + specificity/2) of predicting physical aggressive incidents in patients with schizophrenia ranged from 59.73 to 87.33% at 4-month follow-up, 68.31-80.10% at 12-month follow-up, and 46.22-81.63% at 18-month follow-up, respectively. Additionally, we developed separate models, using clinician rated clinical judgement of short term and immediate violent risk, as a measure of comparison. Several modifiable evidence-based predictors of prospective physical aggression in schizophrenia were identified, including impulse control, substance abuse, impulsivity, treatment non-adherence, mood and psychotic symptoms, substance abuse, and poor family support. To the best of our knowledge, our HARM models are the first to predict longitudinal physical aggression at an individual level in patients with schizophrenia in forensic settings. However, it is important to caution that since these machine learning models were developed in the context of forensic settings, they may not be generalisable to individuals with schizophrenia more broadly. Moreover, a low base rate of physical aggression was observed in the testing set (6.0-11.6% across timepoints). As such, larger cohorts will be required to determine the replicability of these findings.

Female Forensic Patients May Be an Atypical Sub-type of Females Presenting Aggressive and Antisocial Behavior

The percentage of forensic psychiatric patients who are female varies from 5 to 13% in Europe, rises to 18% in England and Wales, and sits at 15% in Canada. Similarly, many fewer women than men are incarcerated in correctional facilities. While these statistics supposedly reflect less antisocial and aggressive behavior (AAB) among females than males, not all findings support this supposition. Data from prospective longitudinal studies show that aggressive and antisocial behavior onsets in childhood, and in a small group of females it remains stable across the life-span. Unlike similar males, few of these females are convicted of crimes. This article begins with a review of descriptive studies of females sentenced by criminal courts to treatment in forensic psychiatric hospitals and moves on to present evidence showing that most female AAB does not lead to criminal prosecution. Next, studies of female AAB are reviewed, noting that it onsets in early childhood and, that in a small group remains stable across the life-span. Subsequent sections of the article focus on the two most common mental disorders presented by female forensic patients, schizophrenia and borderline personality disorder, highlighting what is known about the sub-groups of women with these disorders who present AAB. The article concludes with recommendations for earlier identification by psychiatric services of women presenting mental disorders and AAB, treatments to reduce both the symptoms of their mental disorders and their life-long AAB, and the research that is needed in order to improve the effectiveness of these treatments. The real possibilities of prevention of the development of AAB, and even perhaps aspects of the mental disorders that plague female forensic patients, are described.

Treatment Decision-Making Capacity in Forensic vs Non-forensic Psychiatric Patients: A European Comparison

Background

Consent to treatment is a cornerstone of medical ethics and law. Nevertheless, very little empirical evidence is available to inform clinicians and policymakers regarding the capacities of forensic patients with schizophrenia spectrum disorders (SSDs) to make decisions about their treatment, with the risk of clinical and legal inertia, silent coercion, stigmatization, or ill-conceived reforms.

Study Design

In this multinational study, we assessed and compared with treatment-related decisional capacities in forensic and non-forensic patients with SSD. 160 forensic and 139 non-forensic patients were used in Austria, Germany, Italy, Poland, and England. Their capacity to consent to treatment was assessed by means of the MacArthur Competence Assessment Tool for Treatment (MacCAT-T). Multiple generalized linear regression models were used to identify the socio-demographic and clinical variables associated with MacCAT-T scores.

Study Results

In total, 55 forensic (34.4%) and 58 non-forensic patients (41.7%) showed high treatment-related decisional capacity, defined as scoring ≥75% of the maximum scores for the understanding, appreciation and reasoning, and 2 for expressing a choice. Forensic patients showed differences in their capacity to consent to treatment across countries. Of all socio-demographic and clinical variables, only "social support" was directly relevant to policy.

Conclusions

Forensic patients have treatment-related decisional capacities comparable with their non-forensic counterparts. Social contacts might provide a substantial contribution towards enhancing the decisional autonomy of both forensic and non-forensic patients, hence improving the overall quality and legitimacy of mental health care.