Characteristic hostility in schizophrenic outpatients

The specific anti-hostility effect of lurasidone in patients with an acute exacerbation of schizophrenia: results of pooled post hoc analyses in adolescents and adults

Symptoms of hostility in patients during acute exacerbations of schizophrenia have been associated with aggressive behavior. Data suggest that some second-generation antipsychotics have specific anti-hostility effects, independent of sedation and positive symptom improvement. Two post hoc analyses were performed to examine the efficacy of lurasidone for reducing hostility in patients with schizophrenia. One analysis pooled adults (N = 1168) from 5 placebo-controlled, 6-week trials of lurasidone (40-160 mg). Another analysis pooled younger patients (up to age 25 years, N = 427) from the adult studies and a similarly designed trial of lurasidone (40 or 80 mg) in adolescent patients (13-17 years old). The outcome measure was mean change in the hostility item (P7) of the Positive and Negative Syndrome Scale (PANSS). To address pseudospecificity, results were adjusted for positive symptom change and sedation. In adults with a baseline PANSS hostility score ≥2, significant improvement in hostility was observed for all doses with a dose-related increase in effect size (Cohen's d): lurasidone 40 mg = 0.18, 80 mg = 0.24, 120 mg = 0.36, and 160 mg = 0.53. The same dose-response pattern was observed for the more severe hostility subgroups (P7: ≥3, ≥4), and in the early-onset population. Results suggest that lurasidone has specific, dose-related anti-hostility effects.

Effectiveness of Artificial Intelligence Methods in Personalized Aggression Risk Prediction within Inpatient Psychiatric Treatment Settings—A Systematic Review

Aggression risk assessments are vital to prevent injuries and morbidities amongst patients and staff in psychiatric settings. More recent studies have harnessed artificial intelligence (AI) methods such as machine learning algorithms to determine factors associated with aggression in psychiatric treatment settings. In this review, using Cooper’s five-stage review framework, we aimed to evaluate the: (1) predictive accuracy, and (2) clinical variables associated with AI-based aggression risk prediction amongst psychiatric inpatients. Databases including PubMed, Cochrane, Scopus, PsycINFO, CINAHL were searched for relevant articles until April 2022. The eight included studies were independently evaluated using critical appraisal tools for systematic review developed by Joanna Briggs Institute. Most of the studies (87.5%) examined health records in predicting aggression and reported acceptable to excellent accuracy with specific machine learning algorithms employed (area under curve range 0.75–0.87). No particular machine learning algorithm outperformed the others consistently across studies (area under curve range 0.61–0.87). Relevant factors identified with aggression related to demographic and social profile, past aggression, forensic history, other psychiatric history, psychopathology, challenging behaviors and management domains. The limited extant studies have highlighted a potential role for the use of AI methods to clarify factors associated with aggression in psychiatric inpatient treatment settings.

Glutamine and GABA alterations in cingulate cortex may underlie alcohol drinking in a rat model of co-occurring alcohol use disorder and schizophrenia: an 1H-MRS study

Alcohol use disorder commonly occurs in patients with schizophrenia and significantly worsens the clinical course of the disorder. The neurobiological underpinnings of alcohol drinking are not well understood. Magnetic resonance spectroscopy (MRS) has been used to assess the neurochemical substrates that may be associated with alcohol drinking in patients; however, the causal impact of these findings remains elusive, highlighting the need for studies in animal models. This study performed MRS in the neonatal ventral hippocampal lesioned (NVHL) rat model, a model of co-occurring schizophrenia and substance use disorders. NVHL lesions (or sham surgeries) were performed on post-natal day 7 and animals were given brief exposure to alcohol during adolescence (10% v/v in a 2-bottle choice design). Animals were re-exposed to alcohol during adulthood (20% v/v) until a stable drinking baseline was established, and then forced into abstinence to control for the effects of differential alcohol drinking. Animals were scanned for MRS after one month of abstinence. NVHL rats consumed significantly more alcohol than sham rats and in the cingulate cortex showed significantly higher levels of GABA and glutamine. Significantly lower GABA levels were observed in the nucleus accumbens. No differences between the NVHL and sham animals were observed in the hippocampus. Correlation analysis revealed that GABA and glutamine concentrations in the cingulate cortex significantly correlated with the rats' alcohol drinking prior to 30 days of forced abstinence. These findings suggest that a potential dysfunction in the glutamate/GABA-glutamine cycle may contribute to alcohol drinking in a rat model of schizophrenia, and this dysfunction could be targeted in future treatment-focused studies.

Prevalence and phenomenology of violent ideation and behavior among 200 young people at clinical high-risk for psychosis: an emerging model of violence and psychotic illness

In a previously reported longitudinal study of violent ideation (VI) and violent behavior (VB) among 200 youths at clinical high-risk (CHR) for psychosis, we found that VI, hitherto underinvestigated, strongly predicted transition to first-episode psychosis (FEP) and VB, in close temporal proximity. Here, we present participants' baseline characteristics, examining clinical and demographic correlates of VI and VB. These participants, aged 13-30, were examined at Columbia University Medical Center's Center of Prevention and Evaluation, using clinical interviews and the structured interview for psychosis-risk syndromes (SIPS). At the onset of our longitudinal study, we gathered demographics, signs and symptoms, and descriptions of VI and VB. One-third of participants reported VI (n = 65, 32.5%) at baseline, experienced as intrusive and ego-dystonic, and associated with higher suspiciousness and overall positive symptoms. Less than one-tenth reported VB within 6 months of baseline (n = 17, 8.5%), which was unrelated to SIPS-positive symptoms, any DSM diagnosis or other clinical characteristic. The period from conversion through post-FEP stabilization may be characterized by heightened risk of behavioral disinhibition and violence. We provide a preliminary model of how violence risk may peak at various points in the course of psychotic illness.

Behavioral predictors of alcohol drinking in a neurodevelopmental rat model of schizophrenia and co-occurring alcohol use disorder

Alcohol use disorder commonly occurs in patients with schizophrenia and contributes greatly to its morbidity. Unfortunately, the neural and behavioral underpinnings of alcohol drinking in these patients are not well understood. In order to begin to understand the cognitive and reward-related changes that may contribute to alcohol drinking, this study was designed to address: 1) latent inhibition; 2) conditioning; and 3) extinction of autoshaping in a neurodevelopmental rat model with relevance to co-occurring schizophrenia and alcohol use disorders, the neonatal ventral hippocampal lesioned (NVHL) rat. NVHL lesions (or sham surgeries) were performed on post-natal day 7 (PND7) and animals were given brief exposure to alcohol during adolescent (PND 28-42). Latent inhibition of autoshaping, conditioning and extinction were assessed between PND 72-90. On PND90 animals were given alcohol again and allowed to establish stable drinking. Latent inhibition of autoshaping was found to be prolonged in the NVHL rats; the NVHL rats pre-exposed to the lever stimulus were slower to acquire autoshaping than sham pre-exposed rats. NVHL rats that were not pre-exposed to the lever stimulus did not differ during conditioning, but were slower to extinguish conditioned responding compared to sham controls. Finally, the NVHL rats from both groups drank significantly more alcohol than sham rats, and the extent of latent inhibition predicted future alcohol intake in the pre-exposed animals. These findings suggest that the latent inhibition of autoshaping procedure can be used to model cognitive- and reward-related dysfunctions in schizophrenia, and these dysfunctions may contribute to the development of co-occurring alcohol use.

A longitudinal analysis of the overlap between violence and victimization among adults with mental illnesses

Prior research suggests considerable overlap of violence perpetration and victimization among adults with mental illnesses. However, there has been no examination of how the likelihood of being a victim and/or perpetrator of violence may change over time, nor consideration of clinically-relevant factors affecting these transitions. In a pooled sample of adults with mental illnesses (N=3,473) we employed latent transition analysis to: (a) determine prevalence of four violence and victimization classifications (i.e., non-victim/non-perpetrator, victim only, perpetrator only, and victim-perpetrator) over a 6-month period; (b) calculate the likelihood that adults with mental illnesses will remain in or transition between these classifications over time; and (c) assess the effects of recent substance use, psychiatric symptoms, and suicidal behaviors on transitions over time. At each time point, the majority of participants identified as non-victim/non-perpetrators, followed by victim-perpetrators, victims only, and perpetrators only. Analyses also revealed many individuals transitioned between classifications over time. These distinct pathways towards, and away from, violent outcomes were, in part, a function of recent violence and/or victimization, as well as substance use, psychiatric symptoms, and suicidal behaviors. Findings inform the identification of adults with mental illnesses at risk of violence and victimization and highlight points of intervention.

Assessing the reliability, predictive and construct validity of historical, clinical and risk management-20 (HCR-20) in Mexican psychiatric inpatients

INTRODUCTION

Assessing dangerousness to gauge the likelihood of future violent behaviour has become an integral part of clinical mental health practice in forensic and non-forensic psychiatric settings, one of the most effective instruments for this being the Historical, Clinical and Risk Management-20 (HCR-20).

OBJECTIVE

To examine the HCR-20 factor structure in Mexican psychiatric inpatients and to obtain its predictive validity and reliability for use in this population.

METHOD

In total, 225 patients diagnosed with psychotic, affective or personality disorders were included. The HCR-20 was applied at hospital admission and violent behaviours were assessed during psychiatric hospitalization using the Overt Aggression Scale (OAS). Construct validity, predictive validity and internal consistency were determined.

RESULTS

Violent behaviour remains more severe in patients classified in the high-risk group during hospitalization. Fifteen items displayed adequate communalities in the original designated domains of the HCR-20 and internal consistency of the instruments was high.

CONCLUSION

The HCR-20 is a suitable instrument for predicting violence risk in Mexican psychiatric inpatients.

Effects of iloperidone, combined with desipramine, on alcohol drinking in the Syrian golden hamster

Alcohol use disorder in patients with schizophrenia dramatically worsens their clinical course, and few treatment options are available. Clozapine appears to reduce alcohol use in these patients, but its toxicity limits its use. To create a safer clozapine-like drug, we tested whether the antipsychotic iloperidone, a drug that combines a weak dopamine D2 receptor blockade and a potent norepinephrine alpha-2 receptor blockade would reduce alcohol drinking, and whether its effect on alcohol drinking could be increased if combined with an agent to facilitate norepinephrine activity. Syrian golden hamsters (useful animal model for screening drugs that reduce alcohol drinking in patients with schizophrenia) were given free access to water and alcohol (15% v/v) until stable drinking was established. Animals (n = 6-7/group), matched according to alcohol intake, were treated daily with each drug (iloperidone; clozapine; haloperidol; desipramine [norepinephrine reuptake inhibitor]; with idazoxan [norepinephrine alpha-2 receptor antagonist]) or with a two-drug (iloperidone + desipramine; iloperidone + idazoxan) combination for 14 days. Moderate doses of iloperidone (1-5 mg/kg) significantly reduced alcohol drinking (p < 0.05) in the hamster, whereas higher doses (10-20 mg/kg) did not. In addition, 5 mg/kg of iloperidone reduced alcohol drinking to the same extent as clozapine (8 mg/kg), whereas haloperidol (0.2 mg/kg) did not. Moreover, iloperidone's effects were enhanced via the addition of desipramine (3 mg/kg), but not idazoxan (1.5/3 mg/kg). In this animal model, iloperidone decreases alcohol drinking as effectively as clozapine, and desipramine appears to amplify this effect. The data suggest that iloperidone, alone or in combination with desipramine, should be tested in patients with schizophrenia and alcohol use disorder.

Web-Based Violence Risk Monitoring Tool in Psychoses: Pilot Study in Community Forensic Patients

We describe the development and pilot testing of a novel, web-based, violence risk monitoring instrument for use in community patients with psychoses. We describe the development of the tool, including drawing on systematic reviews of the field, how item content was operationalized, the development of a user interface, and its subsequent piloting. Sixty-eight patients were included from three English counties, who had been discharged from forensic psychiatric services. Over 12 months, 310 questionnaires were completed on the sample by professionals from several disciplines and qualitative feedback collected relating to the use of the tool using an electronic survey. Strengths of this approach for risk assessment, and potential limitations and areas for future research, are discussed.

Predictive validity of the HCR-20 for inpatient aggression: the effect of intellectual disability on accuracy

BACKGROUND

People with intellectual disability (ID) account for a large proportion of aggressive incidents in secure and forensic psychiatric services. Although the Historical, Clinical, Risk Management 20 (HCR-20) has good predictive validity in inpatient settings, it does not perform equally in all groups and there is little evidence for its efficacy in those with ID.

METHOD

A pseudo-prospective cohort study of the predictive efficacy of the HCR-20 for those with ID (n = 109) was conducted in a UK secure mental health setting using routinely collected risk data. Performance of the HCR-20 in the ID group was compared with a comparison group of adult inpatients without an ID (n = 504). Analysis controlled for potential covariates including security level, length of stay, gender and diagnosis.

RESULTS

The HCR-20 total score was a significant predictor of any aggression and of physical aggression for both groups, although the area under the curve values did not reach the threshold for a large effect size. The clinical subscale performed significantly better in those without an ID compared with those with. The ID group had a greater number of relevant historical and risk management items. The clinicians' summary judgment significantly predicted both types of aggressive outcomes in the ID group, but did not predict either in those without an ID.

CONCLUSIONS

This study demonstrates that, after controlling for a range of potential covariates, the HCR-20 is a significant predictor of inpatient aggression in people with an ID and performs as well as for a comparison group of mentally disordered individuals without ID. The potency of HCR-20 subscales and items varied between the ID and comparison groups suggesting important target areas for improved prediction and risk management interventions in those with ID.

Clozapine reconstructed: Haloperidol's ability to reduce alcohol intake in the Syrian golden hamster can be enhanced through noradrenergic modulation by desipramine and idazoxan

BACKGROUND

Alcohol use disorder commonly occurs in patients with schizophrenia. Most antipsychotic drugs do not lessen alcohol use; although the atypical antipsychotic clozapine has been shown to reduce alcohol use in patients with schizophrenia, its toxicity severely limits its use in patients. With an eye toward creation of a safer clozapine-like drug, we have investigated the pharmacological basis of the clozapine's effects on alcohol drinking in the Syrian golden hamster. In this animal, as in patients with schizophrenia, clozapine reduces alcohol drinking while the typical antipsychotic haloperidol does not. We have suggested that clozapine decreases alcohol drinking due to its weak dopamine D2 receptor blockade, its potent norepinephrine α-2 receptor antagonism, as well as its ability to elevate plasma norepinephrine.

METHODS

We recreated a clozapine-like drug to reduce alcohol drinking in the Syrian golden hamster by combining low dose haloperidol with a norepinephrine α-2 receptor antagonist, idazoxan, and a norepinephrine reuptake inhibitor, desipramine. Hamsters were given free access to water and alcohol (15% v/v) and were treated daily with each drug or with the three-drug combination for 23 days.

RESULTS

The drug combination reduced alcohol drinking and preference significantly as compared to vehicle or to haloperidol, idazoxan or desipramine, while not altering food-intake or body-weight.

CONCLUSION

These findings suggest that that haloperidol, which does not reduce alcohol drinking in patients with schizophrenia or the hamster, if combined with idazoxan and desipramine (producing a drug combination that mimics aspects of clozapine's pharmacology) is able to reduce alcohol drinking in the hamster.

Deinstitutionalization and the rise of violence

The deinstitutionalization of individuals with serious mental illness was driven by 4 factors: public revelations regarding the state of public mental hospitals, the introduction of antipsychotic medications, the introduction of federal programs to fund patients who had been discharged, and civil libertarian lawyers. The result is approximately 3.2 million individuals with untreated serious mental illness living in the community. Beginning in the 1970s in the United States, there began to be reported increasing incidents of violent behavior, including homicides, committed by these untreated individuals. Such incidents became more numerous in the 1980s and 1990s, and have further increased since the turn of the century. Existing studies suggest that individuals with untreated severe mental illness are responsible for at least 10% of all homicides and approximately half of all mass killings. Studies have also shown that when these individuals are treated, the incidence of violent behavior decreases significantly. Examples of treatment mechanisms that have proven effective include assisted outpatient treatment (AOT), conditional release, and mental health courts.

The development and trial of a medication discontinuation program in the department of forensic psychiatry

BACKGROUND

When treating mentally ill criminal offenders, improving medication adherence is essential to achieving goals, such as long-term stabilization of symptoms and the prevention of recidivism. Most subjects who are treated under the Medical Treatment and Supervision Act have schizophrenia, which is considered a particularly difficult disorder for which to improve medication adherence. For such patients, we developed a Medication Discontinuation Program (MDP) that aims to improve medication adherence by discontinuing antipsychotic drugs and monitoring changes in psychiatric symptoms. We examined whether there was any utility for the MDP on a trial basis as well as whether it would be worthwhile to introduce the MDP to psychiatric programs.

METHODS

We conducted the MDP with an intervention group (n = 7) and compared Drug Attitude Inventory-30 (DAI-30) scores before and after implementation of the MDP. We also categorized 30 questions of the DAI-30 into three subscales: "awareness of the need for medication", "awareness of the effects of psychiatric drugs", and "impression of medication", and examined factors affecting improvement in medication adherence.

RESULTS

The total DAI-30 score significantly increased after completion of the MDP (P = 0.002). Significant elevations after completion of the MDP were also observed in the scores for three subscales of the DAI-30.

CONCLUSIONS

Our study suggests that the MDP has a possibility of improving medication adherence, and this program might have multidirectional and stimulatory effects on each factor related to the improvement of medication adherence.

An Intervention for Substance Abuse in Schizophrenia

Substance abuse in schizophrenia is a significant management problem for both clients and treatment agencies, impacting on psychotic symptoms, medication adherence, and participation in training and employment. However, there is little published work on the treatment of drug abuse in this population. This paper describes a cognitive-behavioural intervention for alcohol and cannabis abuse which integrates substance abuse treatment with other aspects of psychosis management.

Relief of cannabis withdrawal symptoms and cannabis quitting strategies in people with schizophrenia

This study examined the response to cannabis withdrawal symptoms and use of quitting strategies to maintain abstinence in people with schizophrenia. A convenience sample of 120 participants with schizophrenia who had at least weekly cannabis use and a previous quit attempt without formal treatment were administered the 176-item Marijuana Quit Questionnaire to characterize their "most serious" (self-defined) quit attempt. One hundred thirteen participants had withdrawal symptoms, of whom 104 (92.0%) took some action to relieve a symptom, most commonly nicotine use (75%). 90% of withdrawal symptoms evoked an action for relief in a majority of participants experiencing them, most frequently anxiety (95.2% of participants) and cannabis craving (94.4%). 96% of participants used one or more quitting strategies to maintain abstinence during their quit attempt, most commonly getting rid of cannabis (72%) and cannabis paraphernalia (67%). Religious support or prayer was the quitting strategy most often deemed "most helpful" (15%). Use of a self-identified most helpful quitting strategy was associated with significantly higher one-month (80.8% vs. 73.6%) and one-year (54.9% vs. 41.3%) abstinence rates. Actions to relieve cannabis withdrawal symptoms in people with schizophrenia are common. Promotion of effective quitting strategies may aid relapse prevention.

Factors predicting hostility in outpatients with schizophrenia: 36-month results from the SOHO study

This analysis explored the prevalence, incidence, and predictors of hostility in the European Schizophrenia Outpatient Health Outcomes (EU-SOHO) study. Data were collected at baseline and up to 36 months on the presence of hostility, clinical course and severity, medication compliance, side effects, substance/alcohol abuse, and being a crime survivor. Regression models were fitted to test the association between predictors and the presence of hostility. Hostility prevalence in the 6 months before baseline was 27.9%, and the incidence at 3 years was 14.0%. Variables related to hostility during follow-up were age, male sex, alcohol/substance abuse, tardive dyskinesia, extrapyramidal symptoms, cognitive impairment, noncompliance, and hospitalization. Being a crime survivor, being married, not living independently, and not being in paid employment were associated with hostility at baseline. Clinical and social variables are related to hostility in schizophrenia. Extrapyramidal symptoms and tardive dyskinesia, alcohol/substance abuse, cognitive impairment, medication noncompliance, and hospitalizations are predictors of future hostility.

Symptoms associated with victimization in patients with schizophrenia and related disorders

Background

Patients with psychoses have an increased risk of becoming victims of violence. Previous studies have suggested that higher symptom levels are associated with a raised risk of becoming a victim of physical violence. There has been, however, no evidence on the type of symptoms that are linked with an increased risk of recent victimization.

Methods

Data was taken from two studies on involuntarily admitted patients, one national study in England and an international one in six other European countries. In the week following admission, trained interviewers asked patients whether they had been victims of physical violence in the year prior to admission, and assessed symptoms on the Brief Psychiatric Rating Scale (BPRS). Only patients with a diagnosis of schizophrenia or related disorders (ICD-10 F20–29) were included in the analysis which was conducted separately for the two samples. Symptom levels assessed on the BPRS subscales were tested as predictors of victimization. Univariable and multivariable logistic regression models were fitted to estimate adjusted odds ratios.

Results

Data from 383 patients in the English sample and 543 patients in the European sample was analysed. Rates of victimization were 37.8% and 28.0% respectively. In multivariable models, the BPRS manic subscale was significantly associated with victimization in both samples.

Conclusions

Higher levels of manic symptoms indicate a raised risk of being a victim of violence in involuntary patients with schizophrenia and related disorders. This might be explained by higher activity levels, impaired judgement or poorer self-control in patients with manic symptoms. Such symptoms should be specifically considered in risk assessments.

Cannabis withdrawal in chronic cannabis users with schizophrenia

BACKGROUND

Chronic users of cannabis often report withdrawal symptoms after abstinence from use, but little is known about cannabis withdrawal in people with schizophrenia.

METHODS

Cannabis use patterns and withdrawal symptoms in adults with schizophrenia who had at least weekly cannabis use before attempting to quit without formal treatment were assessed with the Marijuana Quit Questionnaire (MJQQ), a 176-item, semi-structured questionnaire.

RESULTS

120 participants, predominantly African-American (62.5%) and male (76.7%), met inclusion criteria. 20.1% reported that their first regular cannabis use (median age 15 years [range 8-48]) preceded their age at first psychotic symptoms (20 [4-50] years). Twenty (16.7%) participants met lifetime criteria for cannabis abuse; 98 (81.7%) met surrogate criteria for lifetime cannabis dependence. Withdrawal symptoms were reported by 113 (94.2%) participants, with 74.2% reporting ≥4 symptoms. The most frequently reported withdrawal symptoms were craving for cannabis (59.2%), feeling anxious (52.57%), feeling bored (47.5%), feeling sad or depressed (45.8%), feeling irritable or jumpy (45.0%), feeling restless (43.3%), and trouble failing asleep (33.3%). One hundred-and-four (92.0%) participants took some action to relieve at least one of their withdrawal symptoms during their index-quit attempt, including 26 (23.0%) participants who reported resuming cannabis use.

CONCLUSION

Cannabis withdrawal is a clinically significant feature of cannabis use among people with schizophrenia, may serve as a negative reinforcer for relapse, and deserves greater attention in treatment and research. Clinical Trials registration NCT00679016.

Consensus judgments of discharge readiness based on paranoid behavior: to what are clinical staff responding?

BACKGROUND

Salinas et al. (J Consult Clin Psychol 4:1029-1039, 2002) found that, contrary to widely held beliefs, paranoid behavior was a positive prognostic indicator for psychiatric inpatients only due to artifactual restrictions on overall level of functioning that result from traditional classification procedures. Paranoid functioning, in fact, negatively impacted consensus staff discharge-readiness judgments. This discrepancy between clinical lore and empirical findings raises a question about the aspects of paranoid functioning to which staff responds.

METHOD

Those aspects of paranoid functioning are examined in this study, using the same sample of 469 inpatients from 19 treatment units reported in the Salinas et al. investigation.

RESULTS

Both dimensionally measured paranoid functioning and overall level of disability were independently associated with negative discharge-readiness decisions. However, rather than delusions or hallucinations, hostility entirely accounted for the contribution of paranoid functioning to these prognostic judgments.

CONCLUSION

We discuss implications of an alternative approach to classifying patients' problem behavior for clinical research and practice.

Perpetration of violence, violent victimization, and severe mental illness: balancing public health concerns

OBJECTIVE

This review examined U.S. empirical studies published since 1990 of the perpetration of violence and of violent victimization among persons with severe mental illness and their relative importance as public health concerns.

METHODS

MEDLINE, PsycINFO, and Web of Science were searched for published empirical investigations of recent prevalence or incidence of perpetration or victimization among persons with severe mental illness. Studies of special populations were included if separate rates were reported for persons with and without severe mental illness.

RESULTS

The search yielded 31 studies of violence perpetration and ten studies of violent victimization. Few examined perpetration and victimization in the same sample. Prevalence rates varied by sample type and time frame (recall period). Half of the studies of perpetration examined inpatients; of these, about half sampled only committed inpatients, whose rates of perpetration (17%-50%) were higher than those of other samples. Among outpatients, 2% to 13% had perpetrated violence in the past six months to three years, compared with 20% to 34% who had been violently victimized. Studies combining outpatients and inpatients reported that 12% to 22% had perpetrated violence in the past six to 18 months, compared with 35% who had been a victim in the past year.

CONCLUSIONS

Perpetration of violence and violent victimization are more common among persons with severe mental illness than in the general population. Victimization is a greater public health concern than perpetration. Ironically, the discipline's focus on perpetration among inpatients may contribute to negative stereotypes.

[Treatment progress scale for violent psychosis patients]

OBJECTIVES

The dangerousness of psychiatric patients is related to many well-documented factors in literature. To better document the course of dangerousness in most violent psychotic patients with severe and persistent diseases, we have developed a Treatment Progress Scale (TPS).

METHOD

The TPS was developed based on the literature research and the expertise of a multidisciplinary team.

RESULTS

The instrument has good interrater reliability and has shown to be easy to use, after being implemented for 5 years in a treatment unit at Philippe-Pinel Institute. The instrument provides a systematic assessment of important clinical parameters validating treatment observance and patient evolution over months. It also builds on the daily observations made by different members of the multidisciplinary team, the common language of patients and staff, the transparency of our work with patients, and the clear identification of most treatment targets. It also brings a valued complement to the dangerousness assessment.

CONCLUSIONS

The TPS is a relevant instrument for the violent psychotic inpatient specific population. It provides a better identification of treatment progress and helps to specify dangerousness from an evolution perspective. Variations may be developed to assess outpatients and patients in a general setting.

Forensische Patienten und Patienten der Allgemeinpsychiatrie

BACKGROUND

The aim of this study was to assess the potential for future violent behaviour comparing patients recruited from forensic and general psychiatric wards in Germany.

PATIENTS AND METHODS

Fifty patients were recruited from a forensic hospital and 29 from a general psychiatric hospital. In the weeks preceding discharge, structured assessments of the future risk of violent behaviour were completed using the HCR-20.

RESULTS

There was little difference in the risk presented by the two groups. Forensic patients presented an elevated risk of violence because of historical factors, while the risk among patients from general psychiatry was due to clinical symptoms.

CONCLUSION

Some criminal offences could be prevented if more time and effort were spent in general psychiatric practice in identifying patients at high risk for violence and in reducing symptoms of psychoses before discharge.

Randomised clinical trial comparing oral versus depot formulations of zuclopenthixol in patients with schizophrenia and previous violence

PURPOSE

The aim of this longitudinal study was to determine whether the depot formulation of an antipsychotic reduces violence in outpatients with schizophrenia as compared to oral administration of the same antipsychotic.

METHODS

Forty-six previously violent patients with schizophrenia were randomised to receive treatment with oral or depot zuclopenthixol for 1 year. Clinicians interviewed patients at baseline and every month thereafter to assess treatment adherence. An interviewer blinded to treatment assignments interviewed an informant about any violent behaviour during the previous month.

RESULTS

Violence during the follow-up year was inversely proportional to treatment adherence, better compliance, and greater reduction of positive symptoms. Lower frequency of violent acts was observed in the depot group. The level of insight at baseline was not significantly associated with violence recidivism. Regardless of route of administration, treatment non-adherence was the best predictor of violence.

CONCLUSIONS

Some patients with schizophrenia and prior violent behaviour may benefit from the depot formulation of antipsychotic medication.

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

OBJECTIVE

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

CONCLUSION

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

Utility of social cognition and insight in the prediction of inpatient violence among individuals with a severe mental illness

The purpose of this study was to assess the utility of social cognition and insight in the prediction of violence in a psychiatric inpatient sample. Violence history, demographic information, symptomatology, neuropsychological functioning, social cognition (i.e., attributional style), and insight were assessed in 29 inpatients with severe mental illness. Greater posttest violence was associated with greater pretest violence, less education, greater psychiatric distress, neuropsychological impairment, and hostile attributional and personalizing biases. Hierarchical multiple regression analyses showed that history of violence contributed the most variance to posttest violence. Hostile attributional and personalizing biases were also uniquely associated with posttest violence. Overall, this study supported the modest utility of attributional style measures in the prediction of inpatient violence. The predictive value of insight in this context appears limited.

Program-level predictors of antipsychotic medication adherence among parolees

This study examined the impact of three program-level factors (coercion level, type of antipsychotic prescribed, and guardian supervision) on antipsychotic medication adherence among parolees mandated to an outpatient psychiatric clinic. Overall, 70.7% of the participants tested positive for their prescribed antipsychotic. Older patients were more likely to test positive for their prescribed antipsychotic than younger patients, and African American patients (relative to all other race/ethnic groups) were less likely. With regard to program-level factors, perceived coercion was not significantly associated with medication adherence. However, being prescribed an atypical antipsychotic and having a guardian were independently associated with increased adherence, and combined, these two factors were associated with nearly a tenfold increase in the likelihood of patients testing positive for their prescribed antipsychotic agent, relative to patients who were prescribed conventional antipsychotics and were not under guardian supervision.

Clozapine reduces alcohol drinking in Syrian golden hamsters

Alcohol abuse contributes substantially to the overall morbidity of schizophrenia. While typical antipsychotic medications do not limit alcohol use in patients with schizophrenia, emerging data suggest that the atypical antipsychotic clozapine does. To further elucidate the effects of these antipsychotics on alcohol use, we initiated a study in alcohol-preferring rodents. Syrian golden hamsters were given free-choice, unlimited access to alcohol. Nine days of treatment (s.c. injection) with clozapine (2-4 mg/kg/day), but not haloperidol (0.2-0.4 mg/kg/day), reduced alcohol drinking. Clozapine reduced alcohol drinking by 88% (from 11.3+/-1.7 to 1.4+/-0.2 g/kg/day) while increasing both water and food intake. Alcohol drinking gradually (during 24 days) returned toward baseline in the clozapine-treated animals when vehicle was substituted for clozapine. Further increasing the doses of haloperidol (0.6-1.0 mg/kg/day) had no effect on alcohol drinking; moreover, very low doses of haloperidol (0.025-0.1 mg/kg/day) tested in separate groups of hamsters also had no effect on alcohol drinking. This study demonstrates that clozapine, but not haloperidol, can effectively and reversibly decrease alcohol consumption in alcohol-preferring hamsters. The results are compatible with the observations that clozapine, but not haloperidol, limits alcohol use in patients with schizophrenia. These data further suggest that clozapine may serve as a prototype for developing novel treatments for alcohol abuse.

Violence in male patients with schizophrenia: risk markers in a South African population

OBJECTIVE

We investigate the role of functional variants in the catecholamine-O-methyl transferase gene (COMT) and the monoamine oxidase-A gene (MOA-A), as well as previously identified non-genetic risk factors in the manifestation of violent behaviour in South African male schizophrenia patients.

METHOD

A cohort of 70 acutely relapsed male schizophrenia patients was stratified into violent and non-violent subsets, based on the presence or absence of previous or current violent behaviour. Standardized violence rating scales were also applied and the COMT/NlaIII and MAO-A promoter region variable number of tandem repeats (VNTR) polymorphisms were genotyped.

RESULTS

A multiple logistic regression model based on the clinical, genetic and socio-demographic variables indicated that delusions of control (OR = 3.7, 95% CI = 1.21-11.61) and the combined use of cannabis and alcohol (OR = 6.89, 95% CI = 1.28-37.05) were two significant predictors of violent behaviour in this schizophrenia population. No association was found between the tested polymorphisms and violent behaviour.

CONCLUSIONS

Although the sample size may have limited power to exclude a minor role for these specific gene variants, such a small contribution would have limited clinical relevance given the strong significance of the non-genetic markers. These findings suggest that currently proactive management of violent behaviour in this schizophrenia population should continue to be based on clinical predictors of violence.

The promise of prison-based treatment for dually diagnosed inmates

The Stay'n Out therapeutic community was created 25 years ago, the first rigorously evaluated prison program that demonstrated recidivism reduction. Since then, there has been a growing appreciation for the recidivism-reducing benefit of substance abuse treatment and the general understanding has been reached that prison treatment for substance abuse is good for the public interest. A number of replicated outcome studies have led to increases in treatment capacity in most state correctional systems, primarily utilizing the therapeutic community model. In contrast, efforts to introduce treatment for offenders with co-occurring mental illness and substance abuse disorders (COD) are only beginning. This article describes developments in prison substance abuse treatment and reentry programs and offers some guiding observations from prison substance abuse treatment history that could facilitate the development of COD treatment. Lessons learned include that: public safety (i.e., recidivism reduction) is a primary goal; personal accountability as a basic treatment value facilitates cooperation between treatment and correctional staff; self-help approaches foster more ambitious treatment goals than just symptom reduction; and well-run treatment programs often ease the burden of correctional administration.

Connecting neurosis and psychosis: the direct influence of emotion on delusions and hallucinations

Diagnostic classification systems contain a core divide between neurosis and psychosis, leading to their separate study and treatment. The basis for the separation of the disorders is outlined and reassessed. It is argued that the empirical evidence does not support such a sharp distinction between neurosis and psychosis. The frequent occurrence of emotional disorder prior to and accompanying psychosis indicates that neurosis contributes to the development of the positive symptoms of psychosis. Psychological theories and experimental evidence concerning the influence of emotion on the content and form of delusions and hallucinations are therefore reviewed. It is argued that in many cases delusions are a direct representation of emotional concerns, and that emotion contributes to delusion formation and maintenance. The content of hallucinations less often directly expresses the emotional concerns of the individual, but emotion can trigger and contribute to the maintenance of hallucinatory phenomena, although how this occurs is not well understood. It is concluded that study needs to be made of the interaction between psychotic and neurotic processes in the development of delusions and hallucinations, and that neurotic and psychotic disorders may have common maintenance processes.

Alcohol and cannabis use in schizophrenia: effects of clozapine vs. risperidone

BACKGROUND

Alcohol and cannabis use disorders worsen the course of schizophrenia. While the typical antipsychotics are of limited value in controlling substance use in schizophrenic patients, previous studies suggest that the novel antipsychotic clozapine (CLOZ) may decrease their substance use. We describe a retrospective study of the effects of the novel antipsychotics risperidone (RISP) and clozapine on alcohol and cannabis use in patients with schizophrenia or schizoaffective disorder and comorbid alcohol and/or cannabis use disorder.

METHOD

This study involved retrospective assessment of abstinence (cessation of alcohol and cannabis use) in 41 patients treated with either risperidone (n=8) or clozapine (n=33) for at least 1 year. In 32 of these 41 patients, information was available on whether abstinence occurred during the 1-year period.

RESULTS

Abstinence rates were significantly higher in patients treated with clozapine than in those treated with risperidone (54% vs. 13%, p=0.05). The nine patients treated for at least 1 year, but excluded from the analysis because time of cessation of use was not known, had all stopped alcohol/cannabis use during clozapine treatment.

DISCUSSION

While the limitations of this retrospective study must be recognized, the data suggest that comorbid patients treated with clozapine are more likely to abstain from alcohol and cannabis use than are those treated with risperidone. Further prospective studies will be required to confirm these intriguing results.

Neurocognitive and psychosocial correlates of hostility among persons in a post-acute phase of schizophrenia spectrum disorders

Persons with schizophrenia often have difficulty inhibiting hostile behaviors. While the correlates of hostility have been extensively explored in controlled settings, less is known about hostile behaviors and attitudes among outpatients who are in a post-acute phase of illness. Accordingly, this study examined the relationship of self-reported hostile behaviors and attitudes with measures of neurocognition, childhood physical abuse and hopelessness among 36 individuals with schizophrenia or schizoaffective disorder. In a stepwise multiple regression, poorer executive function and a history of childhood physical abuse significantly predicted behavioral hostility (R(2) =.25, P <.05), while attitudinal hostility was uniquely predicted by hopelessness (R(2) =.16, P <.05). Results suggest that behavioral hostility among persons in a stable phase of illness may be closely related to disinhibition and trauma history while hostile attitudes may be more closely linked with attitudes about current psychosocial circumstances.

Interviewing violent patients

A clinical attitude to the interview of violent patients is outlined, which enables maximum safety for the clinician and usefulness of the interview findings. This approach emphasizes careful monitoring of subjective states in the patient and clinician. The author suggests an emphasis on clinical knowledge of the DSM-IV and psychodynamic diagnoses of potentially violent psychiatric patients; self-awareness of transference and countertransference; and self-care including attention to personal physical and emotional needs, de-escalation, and self-defense skills. Finally, there is need for a safe therapeutic context within which to work.

Substance misuse, psychiatric disorder and violent and disturbed behaviour

BACKGROUND

Epidemiological studies suggest schizophrenia and substance misuse to be associated with a higher rate of violence and crime.

AIMS

The literature was evaluated to assess whether people with schizophrenia who use substances have an increased risk for violence and disturbed behaviour.

METHOD

A detailed Medline analysis was performed and relevant studies were reviewed.

RESULTS

A large number of studies have linked substance misuse in schizophrenia with male gender, high incidence of homelessness, more pronounced psychotic symptoms, non-adherence with medication, poor prognosis, violence and aggression. The latter has been proved by clinical, epidemiological and longitudinal prospective studies of unselected birth cohorts. The increased risk for aggression and violent acts cannot be interpreted only as a result of poor social integration. Male gender, more severe psychopathology, a primary antisocial personality, repeated intoxications and non-adherence with treatment are important confounding variables.

CONCLUSION

Substance misuse has been shown consistently to be a significant risk factor for violence and disturbed behaviour. Future research should try to evaluate possible pharmacological and psychosocial treatment approaches.

Effects of clozapine on substance use in patients with schizophrenia and schizoaffective disorder: a retrospective survey

Substance use disorders, particularly those involving alcohol, marijuana, and cocaine, are highly prevalent among patients with schizophrenia and contribute markedly to its overall morbidity. Unfortunately, standard (typical) antipsychotic medications do not seem to reduce substance use in patients with schizophrenia and may even increase it. Recently, however, a few anecdotal case reports and two previous small "N" surveys have found that clozapine, an atypical antipsychotic medication, seems to decrease substance use in patients treated with this drug for their psychoses. The authors report data from a retrospective survey of substance use in 58 patients treated with clozapine who had a history of comorbid schizophrenia (or schizoaffective disorder) and substance use disorder. Of these 58 patients, 43 were being treated with clozapine at the time of the survey; the remaining 15 patients had discontinued clozapine before the survey. The survey involved chart review and clinician interview to assess change in substance use and global clinical symptoms while receiving treatment with clozapine. More than 85% of the patients who were active substance users at the time of initiation of treatment with clozapine decreased their substance use over the course of clozapine administration. For patients who continued treatment with clozapine up to the present, the decrease in substance use was strongly correlated with a decrease in global clinical symptoms. Data from this retrospective survey further support the previous observations that clozapine reduces substance use among patients with schizophrenic disorders. Moreover, the data suggest the need for prospective controlled studies of the effects of clozapine on substance use in this population.

Well Siblings Living With Schizophrenia

As a result of the ongoing hallucinations and delusions, life at home became "anxious and chaotic" with "lots of stress." Because there was no on-site crisis intervention by professionals, well siblings were sometimes called upon to control the violent behavior and were vigilant and fearful regarding the potential for abuse. Negative symptoms were the most disturbing to well siblings. Siblings need help to understand that social isolation and lack of motivation are symptoms of the illness--not due to "laziness."

Gender differences in homeless persons with schizophrenia and substance abuse

The purpose of this study was to test the generalizability of previous research on gender differences between men and women with co-occurring schizophrenia and substance abuse. One hundred eight patients with schizophrenia or schizo-affective disorder involved in a study of treatment for homeless persons were interviewed for information regarding substance use, social functioning and support, comorbid disorders, victimization, medical illness, and legal troubles. We found that women had more children and were more socially connected than men. Women also had higher rates of sexual and physical victimization, comorbid anxiety and depression, and medical illness than men. We conclude that homeless women with dual disorders, like women with substance use disorders in the general population, have distinct characteristics, vulnerabilities, and treatment needs compared with men. In addition to comprehensive treatment of psychiatric and substance use disorders, gender-specific services should be developed, including prevention and treatment of victimization and related problems as well as help with accessing medical services.

Substance misuse and risk of aggression and offending among the severely mentally ill

BACKGROUND

The aim of this study was to investigate whether 'dual diagnosis' (substance misuse and severe mental illness) is associated with aggression and offending.

METHOD

Twenty-seven people meeting the criteria for both psychotic illness and a substance use disorder and 65 people with psychosis only were interviewed. Case notes were also examined and keyworkers asked to rate substance misuse and aggression.

RESULTS

The severity of aggression and offending among this community treatment sample was low. Individuals with a dual diagnosis were significantly more likely than those with psychosis only to report any history of committing an offence (P = 0.001), or recent hostile behaviour (P = 0.001). Keyworkers were more likely to report recent aggression among the dually diagnosed (P = 0.01). Significant differences persisted when we used logistic regression to control for potentially confounding demographic and clinical variables.

CONCLUSIONS

Dual diagnosis may be an important factor in aggression and offending among severely mentally ill individuals in inner-city areas. Accurate risk assessment requires examination of substance use.

Violence and severe mental illness: the effects of substance abuse and nonadherence to medication

OBJECTIVE

Violent behavior among individuals with severe mental illness has become an important focus in community-based care. This study examines the joint effect of substance abuse and medication noncompliance on the greater risk of serious violence among persons with severe mental illness.

METHOD

Involuntarily admitted inpatients with severe mental illness who were awaiting a period of outpatient commitment were enrolled in a longitudinal outcome study. At baseline, 331 subjects underwent an extensive face-to-face interview. Complementary data were gathered by a review of hospital records and a telephone interview with a family member or other informant. These data included subjects' sociodemographic characteristics, illness history, clinical status, medication adherence, substance abuse, insight into illness, and violent behavior during the 4 months that preceded hospitalization. Associations between serious violent acts and a range of individual characteristics and problems were analyzed by using multivariable logistic regression.

RESULTS

The combination of medication noncompliance and alcohol or substance abuse problems was significantly associated with serious violent acts in the community, after sociodemographic and clinical characteristics were controlled.

CONCLUSIONS

Alcohol or other drug abuse problems combined with poor adherence to medication may signal a higher risk of violent behavior among persons with severe mental illness. Reduction of such risk may require carefully targeted community interventions, including integrated mental health and substance abuse treatment.

Complications of severe mental illness related to alcohol and drug use disorders

In this chapter we review research on the relationships between substance use disorder and 11 domains of adjustment for people with severe mental illness. Studies are divided into correlational research and prospective, longitudinal research, with greater weight given to those in the latter category. The weight of the evidence indicates that substance abuse severely complicates severe mental illness in the following domains: relapse of psychiatric illness, hospitalization, disruptive behavior, familial problems, residential instability, decreased functional status, HIV infection, and medication noncompliance. We discuss the limits of causal inference in these studies and the possible mechanisms that relate substance abuse to various complications.