Rates of homicide during the first episode of psychosis and after treatment: a systematic review and meta-analysis

Distinct trajectories of psychotic-like experiences and their associations with violent behavior among 3539 young adults: A 3-year prospective cohort study

BACKGROUND

Violence perpetration may be linked to psychotic-like experiences (PLEs), but relevant research is limited, especially in general population. Therefore, we aimed to identify trajectories of PLEs and examine whether specific trajectories were related to violent behavior in a 3-year cohort study.

METHODS

We developed a prospective cohort study and collected data in 2020 (T0), 2021 (T1), and 2022 (T2) in Guangzhou, China. A total of 3539 university students from two universities were included and completed self-report questionnaires to assess PLEs, violent ideation, violent threats, and violent acts. Socio-demographic and clinical factors were assessed and considered as confounding factors. We used growth mixture modeling to identify trajectories of PLEs. Associations between PLEs trajectories and violent behavior were examined using binary logistic regression.

RESULTS

At T2, 162 (5.3 %) participants had violent behavior. We identified three distinct trajectories: low stable trajectory, low increasing trajectory, and high decreasing trajectory. The binary logistic regression models revealed that the high decreasing (OR: 2.46, 95%CI:1.60-3.72) group and the low increasing (OR: 11.7, 95%CI: 7.62-17.9) were associated with higher violent risk compared to the low stable group after controlling for baseline socio-demographic and clinical factors.

CONCLUSION

Our study delineated three distinct trajectories and indicated that PLEs trajectories are related to subsequent violent ideation and violent acts. The results provide crucial clarifications regarding the nature of the associations between PLEs trajectories and violence over time.

What do we know now about evidence-based treatment for psychosis and aggressive behaviour or criminality that we did not know when community care was implemented?

PURPOSE

Community care replaced institutional care for people with psychosis without guidance about what constituted effective treatment. In a Swedish birth cohort, many of those who developed schizophrenia or bipolar disorder as community care was being implemented were subsequently convicted of violent and non-violent crimes. Studies from other countries that were implementing community care at this time also reported elevated proportions of patients acquiring criminal convictions. Since community care was first implemented, much has been learned about factors that promote and treatments that limit aggressive/antisocial behaviour/criminality (AABC) among people with psychosis. Without the benefit of this knowledge, did mental health policy and practices that were in place as the asylums were closed inadvertently contribute to criminality?

MATERIAL AND METHODS

This article provides a narrative review of current evidence of effective treatments and management strategies to reduce AABC among patients with psychosis.

RESULTS

Reductions in AABC are associated with stable contact with psychiatric services, second-generation antipsychotic medication, clozapine for patients with schizophrenia and elevated levels of hostility and/or a history of childhood conduct disorder, abstinence from substances, avoidance of trauma, and constant monitoring of both illness symptoms and AABC.

CONCLUSIONS

Failure to adopt evidence-based practices allows the problem of AABC to persist, prevents patients from experiencing independent, safe, community tenure, and puts those around them at risk. Many challenges remain, including implementing effective assessment and interventions at first-episode and convincing patients with antisocial attitudes and behaviours to participate in treatment programs to reduce AABC and to learn prosocial behaviours.

Effect of personality traits, psychological resilience and life adversities on lifetime violence trajectories: A novel classification model in schizophrenia

The risk of violence is higher in schizophrenia spectrum disorders (SSD) compared to the general population and it is a pressing and understudied issue. Several dispositional and environmental factors have been previously correlated with violence, however, there has been little success in assessing their ability to predict violence patterns across the life span. This study aims to assess violence prediction based on personality traits, psychological resilience, and life-course adversities in a non-forensic population of SSD patients. In a sample of 231 patients with SSD, we assessed violence using the Brown-Goodwin History of Lifetime Aggression Scale and conducted cross-sectional assessments of possible predictors such as childhood trauma, personality traits and resilience scores. We then utilized a logistic regression classification algorithm to predict different violence trajectories based on the proposed risk factors. Our model significantly predicted individuals with violence in both childhood and adulthood, as well as childhood-only violence (p < 0.001). However, the model did not show significance for adult-only violence (p = 0.604). In all given trajectories, female sex appeared to be protective against violence, while stressful life events appeared to contribute to it. These results suggest that distinct factors can better inform risk assessment of lifespan violence patterns for personalized interventions in SSD.

Gender-Specific Pathways in Violent Crime: Investigating the Role of Demographic and Mental Health Factors Using Mixed Graphical Models and Bayesian Networks

This research aims to uncover gender-specific relationships and pathways that contribute to the perpetration of violent crimes, using sophisticated analytical tools to analyze the complex interactions between various factors. Employing Mixed Graphical Models and Bayesian networks, the study analyzes a sample of 1,254 prisoners (61.64% males and 38.36% females) to investigate the relationships among demographic factors, mental health issues, and violent crime. The study utilizes comprehensive measures, including the Beck Depression Inventory, Beck Anxiety Inventory, and Childhood Trauma Questionnaire, to assess participants' mental health status.Key findings reveal significant gender differences in the pathways to violent crime. For males, incomplete parental marriages strongly correlate with criminal behavior severity, while marriage status emerges as a significant factor, with married males less likely to commit violent crimes. In contrast, these relationships are not significant for females. Bayesian network analysis indicates that living in urban areas differently influences education and emotional expression across genders, emphasizing the importance of contextual factors. The study highlights the need for gender-specific considerations in criminal justice policies and interventions. It underscores the complex interplay of demographic and mental health factors in influencing violent crime pathways, providing insights for developing more effective prevention strategies. Despite its cross-sectional design and reliance on self-reported data, the research significantly contributes to understanding the gendered dimensions of criminal behavior.

Systematic Review and Meta-analysis: Rates of Violence During First-Episode Psychosis (FEP)

BACKGROUND

Most people with psychotic disorders will never commit an act of violence. However, the risk of violence committed by people with schizophrenia is higher than the general population. Violence risk is also known to be highest during the first episode of psychosis compared to later stages of illness. Despite this, there have been no comprehensive reviews conducted in the past 10 years examining rates of violence during FEP. We aimed to provide an updated review of the rate of violence in people with FEP.

STUDY DESIGN

Meta-analytical techniques were used to identify pooled proportions of violence according to severity (less serious, serious, severe) and timing of violence (before presentation, at first presentation, after presentation to services).

STUDY RESULTS

Twenty-two studies were included. The pooled prevalence was 13.4% (95% CI [9.0%-19.5%]) for any violence, 16.3% (95% CI [9.1%-27.4%]) for less serious violence, 9.7% (95% CI [5.4%-17.0%]) for serious violence and 2.7% for severe violence, regardless of time point. The pooled prevalence of any violence was 11.6% (95% CI [6.8%-18.9%]) before presentation, 20.8% (95% CI [9.8%-38.7%]) at first presentation and 13.3% (95% CI [7.3%-23.0%]) after presentation to services.

CONCLUSION

Overall, rates of violence appear to be lower in more recent years. However, due to the high between-study heterogeneity related to study design, the findings must be interpreted with consideration of sample characteristics and other contextual factors. The prevalence of violence remained high at all-time points, suggesting that more targeted, holistic, and early interventions are needed for clinical FEP groups.

The burden for clinical services of persons with an intellectual disability or mental disorder convicted of criminal offences: A birth cohort study of 14,605 persons followed to age 64

BACKGROUND

Intellectual disability (ID), schizophrenia spectrum disorder (SSD), bipolar disorder (BD), substance use disorder (SUD), and other mental disorders (OMDs) are associated with increased risks of criminality relative to sex-matched individuals without these conditions (NOIDMD). To resource psychiatric, addiction, and social services so as to provide effective treatments, further information is needed about the size of sub-groups convicted of crimes, recidivism, timing of offending, antecedents, and correlates. Stigma of persons with mental disorders could potentially be dramatically reduced if violence was prevented.

METHODS

A birth cohort of 14,605 persons was followed to age 64 using data from Swedish national health, criminal, and social registers.

RESULTS

Percentages of group members convicted of violence differed significantly: males NOIDMD, 7.3%, ID 29.2%, SSD 38.6%, BD 30.7%; SUD 44.0%, and OMD 19.3%; females NOIDMD 0.8%, ID 7.7%, SSD 11.2%, BD 2.4%, SD 17.0%, and OMD 2.1%. Violent recidivism was high. Most violent offenders in the diagnostic groups were also convicted of non-violent crimes. Prior to first diagnosis, convictions (violent or non-violent) had been acquired by over 90% of the male offenders and two-thirds of the female offenders. Physical victimization, adult comorbid SUD, childhood conduct problems, and adolescent substance misuse were each associated with increased risks of offending.

CONCLUSION

Sub-groups of cohort members with ID or mental disorders were convicted of violent and non-violent crimes to age 64 suggesting the need for treatment of primary disorders and for antisocial/aggressive behavior. Many patients engaging in violence could be identified at first contact with clinical services.

The TCO concept in German forensic homicide offenders with schizophrenia spectrum disorders - new findings from a file-based, retrospective cross-sectional study

Introduction

There is evidence that there is a small group of people with schizophrenia spectrum disorders who are more likely to commit homicide than those in the general population. However, there is limited knowledge about the psychopathology that leads to homicide in this group. The aim of this study was to examine two commonly used definitions of the Threat/Control-Override (TCO) concept, which aims to identify a certain risk of serious violence in patients with schizophrenia spectrum disorders.

Methods

This is a sub analysis of a file-based, retrospective and exploratory cross-sectional study. All forensic homicide offenders with schizophrenia spectrum disorders who were detained at the Forensic Hospital Berlin as of 31 December 2014 were examined for the occurrence of TCO according to two commonly used definitions.

Results

Of a total of 419 forensic patients with schizophrenia spectrum disorders, 78 committed homicide (18.6%). The forensic homicide offenders with schizophrenia spectrum disorders were characterised by being male, unemployed, single and having committed (attempted) manslaughter. Irrespective of the definition used, the entire TCO complex was present in less than a third of the sample. In both definitions, Threat symptoms were slightly less frequent than Control-Override symptoms. While Threat symptoms occurred less frequently in Stompe et al.'s definition, Control-Override symptoms were the most common. With regard to Kröber's definition of Threat and Control-Override, the situation is exactly the opposite.

Discussion

Regarding the entire TCO complex, Kröber's definition seems a little more open and Stompe et al.'s more strict (38.5% vs. 35.9%). Since TCO only occurs in about one third of the subjects in both definitions, neither definition appears to be conclusive. A combination with proportions from both definitions could be a contribution to a future definition of TCO. The present study provides scarcely published primary data on psychopathology in homicide offenders with schizophrenia spectrum disorders, especially on the much discussed TCO concept in two definitions. In order to determine the most useful definition of TCO, to avoid false positives and to identify clear psychopathological risk symptoms, larger samples and comparative studies with offenders and non-offenders should be conducted in the future.

Exploring Characteristics of Homicide Offenders With Schizophrenia Spectrum Disorders Via Machine Learning

The link between schizophrenia and homicide has long been the subject of research with significant impact on mental health policy, clinical practice, and public perception of people with psychiatric disorders. The present study investigates factors contributing to completed homicides committed by offenders diagnosed with schizophrenia referred to a Swiss forensic institution, using machine learning algorithms. Data were collected from 370 inpatients at the Centre for Inpatient Forensic Therapy at the Zurich University Hospital of Psychiatry. A total of 519 variables were explored to differentiate homicidal and other (violent and non-violent) offenders. The dataset was split employing variable filtering, model building, and selection embedded in a nested resampling approach. Ten factors regarding criminal and psychiatric history and clinical factors were identified to be influential in differentiating between homicidal and other offenders. Findings expand the research on influential factors for completed homicide in patients with schizophrenia. Limitations, clinical relevance, and future directions are discussed.

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.

Early phase psychosis and criminal conviction in United States adults

AIM

Individuals experiencing early phase psychosis (EPP) are at increased risk for legal involvement. In prior studies, between 14% and 75% of individuals with EPP reported a history of criminal offending behaviour, criminal charges, or criminal convictions. To better understand the frequency of criminal conviction in a specialty treatment clinic serving EPP clients, the research team supplemented self-reported data from the clinic intake with information from publicly available databases.

METHODS

In this sample of 309 adults, approximately one quarter of patients (n = 76) self-reported a history of arrest, incarceration, probation, or parole within 6 months of enrolment in a treatment clinic. The research team expanded upon this and collected data from a public database of court proceedings in Indiana for all clinic participants before and after enrolment.

RESULTS

Thirty-nine percent (n = 122) had three or more traffic tickets or a conviction for an ordinance violation, misdemeanour, or felony in the state of Indiana as an adult. This is over two times the national average. Drug and alcohol related convictions were the most common single conviction type, and 29% (n = 89) of subjects experienced at least one incarceration.

CONCLUSIONS

These data highlight the need for specialty clinics to partner with professionals with expertise in the prevention and management of criminal behaviour. Future studies should examine risk factors for individuals experiencing EPP and criminal conviction.

Homicide in the context of psychosis: analysis of prior service utilisation and age at onset of illness and violence

BACKGROUND

Public stigma and fear are heightened in cases of extreme violence perpetrated by persons with serious mental illness (SMI). Prevention efforts require understanding of illness patterns and treatment needs prior to these events unfolding.

AIMS

To examine mental health service utilisation by persons who committed homicide and entered into forensic care, to investigate the adequacy of mental healthcare preceding these offences.

METHOD

Forensic patients across two mental health hospitals in Ontario with an admitting offence of homicide between 2011 and 2021 were identified (n = 112). Sociodemographic, clinical and offence-related variables were coded from the health record and reports prepared for the forensic tribunal.

RESULTS

Most patients (75.7%) had mental health contacts preceding the homicide, with 28.4% having a psychiatric in-patient admission in the year prior. For those with service contacts in the year preceding, 50.9% had had only sporadic contact and 70.7% were non-adherent with prescribed medications. Victims were commonly known to the individual (35.7%) and were often family members in care-providing roles (55.4%). Examination of age at onset of illness and offending patterns suggested that most persons admitted to forensic care for homicide act in the context of illness and exhibit a low frequency of pre-homicide offending.

CONCLUSIONS

Many individuals admitted to forensic care for homicide have had inadequate mental healthcare leading up to this point. Effective responses to reduce and manage risk should encompass services that proactively address illness-related (e.g. earlier access and better maintenance in care) and criminogenic (e.g. substance use treatment, employment and psychosocial supports) domains.

Risk of violent behaviour in young people at clinical high risk for psychosis from the North American Prodrome Longitudinal Studies consortium

AIM

Although violent behaviour has been studied in schizophrenia, violence risk has received little attention in individuals at clinical high risk for psychosis (CHR). This manuscript aims to report and discuss the overall results of the Structured Assessment for Violence Risk in Youth (SAVRY) from the NAPLS-3 project to explore the risk of violence in CHR youth and to determine the relationship between SAVRY violence risk scores, psychosis risk symptoms, and global functioning. We hypothesized that CHR young people are at higher risk of violence as compared to healthy comparison participants due to a similarity between risk factors for psychosis and risk factors for violence, and that this risk is associated with greater severity of symptoms, poor functioning, and risk for conversion to psychosis.

METHODS

Participants from the North American Prodrome Longitudinal Study consortium phase 3 (NAPLS-3) included 684 CHR and 96 HC. Assessments included the Structural Assessment of Violence Risk in Youth (SAVRY), clinical and functional measures.

RESULTS

The majority of participants across groups were deemed to be at low risk for violence. There were significantly more CHR participants (29.8%) who had moderate or high scores on the SAVRY Summary Risk Rating compared to HC participants (3.1%). Low versus moderate-high SAVRY scores were associated with better social (p < .005) and role (p < .002) functioning and fewer positive (p < .002), negative (p < .002), disorganized (p < .01) and general symptoms (p < .002). CHR participants with higher SAVRY scores were more likely to be diagnosed with borderline personality disorder, ADHD and substance misuse. Among CHR, overall violence risk was not associated with conversion to psychosis. However, those who converted to psychosis scored lower on the protective factors index, primarily driven by less prosocial involvement and fewer resilient personality traits.

CONCLUSIONS

This is the first study to assess violence risk in CHR adolescents. Violence risk factors overlap with risk factors for psychosis in general, perhaps accounting for the association. These findings have implications for intervention efforts to reduce violence risk and bolster resiliency in CHR youth.

Risk factors for violence among female forensic inpatients with schizophrenia

Introduction

Schizophrenia is associated with a heightened risk of violent behavior. However, conclusions on the nature of this relationship remain inconclusive. Equally, the empirical evidence on female patients with schizophrenia spectrum disorders (SSD) is strongly underrepresented.

Methods

For this purpose, the first aim of the present retrospective follow-up study was to determine the risk factors of violence in a sample of 99 female SSD patients discharged from forensic psychiatric treatment between 2001 and 2017, using three different measures of violence at varying time points (i.e., violent index offense, inpatient violence, and violent recidivism). Potential risk factors were retrieved from the relevant literature on SSD as well as two violence risk assessment instruments (i.e., HCR-20 V3, FAM). Further, we aimed to assess the predictive validity of the HCR-20 V3 in terms of violent recidivism and evaluate the incremental validity of the FAM as a supplementary gender-responsive assessment.

Results

The given results indicate strong heterogeneity between the assessed violence groups in terms of risk factors. Particularly, violence during the index offense was related to psychotic symptoms while inpatient violence was associated with affective and behavioral instability as well as violent ideation/intent, psychotic symptoms, and non-responsiveness to treatment. Lastly, violent recidivism was related to non-compliance, cognitive instability, lack of insight, childhood antisocial behavior, and poverty. Further, the application of the HCR-20 V3 resulted in moderate predictive accuracy (AUC = 0.695), while the supplementary assessment of the FAM did not add any incremental validity.

Discussion

This article provides important insights into the risk factors of violence among female SSD patients while highlighting the importance of differentiating between various forms of violence. Equally, it substitutes the existing evidence on violence risk assessment in female offenders with SSD.

Serious Mental Illness and Sexual Offending in Forensic Psychiatric Patients

The role of serious mental illness among those who sexually offend is not well understood. We investigated clinical and risk-related areas of difference between male forensic psychiatric patients with (n = 86) and without (n = 245) a sexual offense history, including the age at which indications of mental disorder and criminal offending first emerged, from a registry of Ontario patients adjudicated Not Criminally Responsible on account of Mental Disorder (NCRMD) from 1999-2012. We further explored motivations for offending among a subset of patients deemed NCRMD for a sexual offense specifically (n = 41). While no differences were found in the age onset of illness or offending across those with and without a sexual offending history, the former group was rated as having higher levels of historical/static risk for violence. Forensic patients with a sexual offense history were also more likely to offend against a stranger, and less likely to offend against a family member. Sexual index offenses were psychotically-motivated in the majority of cases, but with a meaningful proportion appearing to reflect criminogenic motivations, especially substance use and paraphilic interests. Results suggest greater similarity than difference among forensic patients with and without a sexual offense history, but also highlight an important divergence from the literature showing that victims of sexual offenses are frequently known to the individual committing them.

Socio-demographic, clinical and offense-related characteristics of forensic psychiatric inpatients in Hunan, China: a cross-sectional survey

BACKGROUND

There is still a lack of comprehensive research on the profile of patients in forensic mental health hospitals in China. This study aims to investigate the socio-demographic, clinical, and offense-related characteristics of mentally ill offenders in the Hunan Provincial Forensic Psychiatric Hospital in China.

METHODS

This study was conducted from November 1, 2018, to January 30, 2019. The data of socio-demographic, clinical, and offense-related characteristics of the patients were collected. The Brief Psychiatric Rating Scale (BPRS), the Modified Overt Aggression Scale (MOAS), and the Clinical Global Impression-Severity (CGI-S) scale were used to measure their psychiatric conditions.

RESULTS

A total of 461 participants were enrolled in this study. Among them, 86.3% were males and 56.8% were unmarried; the average age of them was 44.7 ± 10.1 years, and the mean years of education were 7.51 ± 3.3 years. Before their current offense, a total of 345 patients (74.8%) had sought medical help for their mental illnesses. While 303 (87.8%) of these patients were prescribed antipsychotics, 254 (73.6%) failed to take them regularly. Of all the inpatients, 90.5% were diagnosed with schizophrenia; 385 (83.5%) engaged in homicidal offenses, with 54.0% of the victims being their family members. In homicide cases, the relatives were more likely to be victims of female patients. The mean length of stay in the forensic hospital was 8.02 ± 4.74 years, and over 80.0% of the patients had been hospitalized for over 5 years.

CONCLUSIONS

To our knowledge, this is the first study investigating the profile of forensic patients receiving compulsory treatments in a forensic psychiatric hospital in China. These results add to the world literature on the characteristics of forensic patients and can help identify common treatment and risk-related needs of this population.

Homicide associated with psychotic illness: What global temporal trends tell us about the association between mental illness and violence

Available evidence suggests that persons with serious forms of mental illness are 4-10 times more likely to commit homicide as compared to non-affected members of the general population. The relationship between homicide and psychotic illness has now been subject to longitudinal investigation in six different populations across eight studies covering time periods over the last six decades. With the exception of one study, these investigations demonstrate that homicide associated with psychotic illness appears relatively stable through time and, in most populations, is not related to factors that contribute to the rise and fall of total population homicide (TPH) rates. This suggests that illness and treatment factors are of most importance if we are to reduce the prevalence of this tragic illness complication.

Child abuse and aggressiveness in individuals diagnosed with schizophrenia in Lebanon

OBJECTIVES

To identify individual and clinical risk factors of aggressiveness, including exposure to different forms of childhood trauma, in a sample of Lebanese patients with schizophrenia.

METHODS

A total of 131 patients diagnosed with schizophrenia participated in this cross-sectional study.

RESULTS

Higher physical (Beta = 0.24, p < 0.001) and sexual (Beta = 0.29, p = 0.003) abuse, alcohol drinking (Beta = 1.46, p = 0.008), having a history of head trauma (Beta = 1.10, p = 0.041), and male gender (Beta = -1.59, p = 0.009) were significantly associated with higher mean aggression scores.

PRACTICAL IMPLICATIONS

Our investigation of the factors linked to aggressiveness in patients with schizophrenia complement those of earlier findings, showing that the relationship between interacting individual and environmental risk factors and later aggressiveness is quite complex, and needs further longitudinal and prospective studies.

Positive and negative syndrome scale in forensic patients with schizophrenia spectrum disorders: a systematic review and meta-analysis

Among forensic patients with schizophrenia spectrum disorders, the association between symptomatology and violence is still not entirely clear in literature, especially because symptoms shift both during the acute phase of the illness and after. The aims were to investigate the level of symptomatology in forensic patients and to evaluate if there are differences in the level of symptoms between forensic and non-forensic patients. According to PRISMA guidelines, a systematic search was performed in PubMed, Web of Science, and ProQuest, using the following key words: "forensic" AND "Positive and Negative Syndrome Scale" OR "PANSS". A total of 27 studies were included in the systematic review, while only 23 studies in the meta-analysis. The overall sample included a total of 1702 participants, most commonly male and inpatients in forensic settings. We found that studies with an entirely male sample had significantly lower Positive PANSS ratings than studies with mixed samples. Although both forensic and non-forensic patients were affected by mild psychopathological symptoms, forensic patients presented higher ratings in all four PANSS scales. This meta-analysis shows that forensic patients reported a mild level of symptomatology, as assessed with the PANSS, and therefore might be considered as patients in partial remission. Among patients with schizophrenia, the association between symptoms and violence is very complex: many factors might be considered as key mediators and thus should be taken into account to explain this association. Further studies are needed.Trial registration all materials and data can be found on the OSF framework: https://osf.io/5ceja (date of registration: 8 September 2021).

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.

Rates of homicide and homicide associated with severe mental illness in NSW between 1993 and 2016

OBJECTIVE

To describe the characteristics of offenders found not guilty on the grounds of mental illness (NGMI) in New South Wales and rates of NGMI and other homicide verdicts.

METHOD

Demographic, legal and clinical data after referral to the NSW Mental Health Review Tribunal following an NGMI verdict for homicide matched with results from the National Homicide Monitoring Program.

RESULTS

Between 1993 and 2016, a total of 2159 homicide offenders were dealt with by the NSW courts, including 169 (7.8%) who were found NGMI. Over this period, the rate of non-NGMI homicide convictions fell from 1.83 per 100,000 per annum to 0.65 per 100,000 per annum (Kendall's tau = -0.79, p ⩽ 0.001) while the rate of NGMI homicide fluctuated, with an average annual rate of about 0.1 per 100,000 per annum (Kendall's tau = 0.17, p = 0.23). There was no association between the annual rates of NGMI and non-NGMI homicides (Pearson r = -0.3, p = 0.16) but falling rate of non-NGMI homicide meant that the proportion of NGMI offences doubled from 5.5% in the first 12 years to 11% in the second 12 years. Nearly all (88.7%) of those found NGMI had a schizophrenia-related psychosis. However, there were high rates of psychiatric comorbidity including substance use disorder (60.7%) and a history of a prior head injury (41.1%). Most (83.4%) of the NGMI offenders had previous contact with mental health services, but only half of these had received treatment with antipsychotic medication.

CONCLUSION

The fall in conviction for homicide offences in the last 24 years has not been matched by a reduction in NGMI homicide verdicts. More assertive treatment of emerging psychosis and comorbid substance use disorders, and improved continuity of care of chronic psychosis might prevent some homicides.

Effects of Integrated Moral Reasoning Development Intervention for Management of Violence in Schizophrenia: A Randomized Controlled Trial

Moral cognition is an important and multidimensional, but often overlooked, determinant of violence. Very few interventions have systematically examined the role of moral reasoning, anger management and problem-solving together in violence. A randomized controlled trial was conducted to comprehensively evaluate the sustained effects of an integrated Moral Reasoning Development Intervention (MRDI) in the management of repetitive violence in schizophrenia. This study placed special emphasis on essential components related to moral reasoning and violence in patients with schizophrenia. Evaluations, including measures of violence, moral reasoning, ethical valuation and judgement, decision-making, conflict management style, and personality traits, were performed at baseline, end of intervention, and 1-month follow-up after intervention. We found that MRDI was superior to treatment-as-usual, in improving moral reasoning and related variables and violence outcomes (p < 0.05). In comparison with the treatment-as-usual group (n = 22), patients in the MRDI group (n = 21) showed improved levels of moral reasoning, with decreased levels of violent behaviors. The MRDI participants also experienced significantly greater improvements or changes (p < 0.05) in their ethical valuation and judgement, decision-making style and preferences, and conflict management style. Our findings provide important implications for risk assessment and violence management and prevention.

Violence, neurocognitive function and clinical correlates in patients with schizophrenia

BACKGROUND

Schizophrenia patients with violent behavior are a severe public health concern, but the correlates of this violent behavior are unknown. Additionally, the relationship between neurocognitive function and violent behavior in Chinese patients with schizophrenia has not yet been investigated.

METHODS

A total of 337 schizophrenia inpatients were recruited. The Positive and Negative Syndrome Scale (PANSS) was used to assess psychopathological symptoms. Neurocognitive functioning was evaluated using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS).

RESULTS

The percentage of violent behavior was 10.4% in patients with schizophrenia. Patients with violent behavior had higher PANSS-positive, excited, and total subscale scores than patients who did not show violent behavior. Patients with violent behavior also had lower RBANS language, semantic fluency, and total subscale scores. Gender (OR = 0.066∼0.819, p = 0.023), illness duration (OR = 0.876∼0.971, p = 0.002), smoking (OR = 1.127∼2.950, p = 0.014), the PANSS positive subscale (OR = 1.050∼1.197, p = 0.001), and the RBANS language subscale (OR = 0.927∼0.987, p = 0.005) significantly contributed to the development of violent behavior in schizophrenia patients.

CONCLUSION

Our findings revealed that cognitive and clinical assessments should be considered in comprehensive assessments of future risks of violence in schizophrenia patients.

Could Expanding and Investing in First-Episode Psychosis Services Prevent Aggressive Behaviour and Violent Crime?

OBJECTIVE

Some persons developing, or presenting, schizophrenia engage in aggressive behaviour (AB) and/or criminal offending. Most of these individuals display AB prior to a first episode of psychosis (FEP). In fact, approximately one-third of FEP patients have a history of AB, some additionally display other antisocial behaviours (A+AB). The large majority of these individuals have presented conduct problems since childhood, benefit from clozapine, have extensive treatment needs, and are unlikely to comply with treatment. A smaller sub-group begin to engage in AB as illness onsets. A+AB persists, often for many years in spite of treatment-as-usual, until a victim is seriously harmed. This article proposes providing multi-component treatment programs at FEP in order to prevent aggressive and antisocial behaviours of persons with schizophrenia.

METHOD

Non-systematic reviews of epidemiological studies of AB among persons with schizophrenia, of the defining characteristics of sub-types of persons with schizophrenia who engage in AB and their responses to treatment, and of FEP service outcomes.

RESULTS

Studies have shown that mental health services that simultaneously target schizophrenia and aggressive behaviour are most effective both in reducing psychotic symptoms and aggressive behaviour. Evidence, although not abundant, suggests that a multi-component treatment program that would include the components recommended to treat schizophrenia and cognitive-behavioural interventions to reduce A+AB, and the other factors promoting A+AB such as substance misuse, victimisation, and poor recognition of emotions in the faces of others has the potential to effectively treat schizophrenia and reduce A+AB. Patients with a recent onset of AB would require few components of treatment, while those with prior conduct disorder would require all. Such a program of treatment would be long and intense.

CONCLUSIONS

Trials are needed to test the effectiveness of multi-component treatment programs targeting schizophrenia and A+AB at FEP. Studies are also necessary to determine whether providing such programs in hospitals and/or prisons, with long-term community after-care, and in some cases with court orders to participate in treatment, would enhance effectiveness. Whether investing at FEP would be cost-effective requires investigation.

Incomplete homicide-suicide in Hunan China from 2010 to 2019: characteristics of surviving perpetrators

BACKGROUND

The mental and psychological conditions of the individuals involved in homicide followed by suicide (H-S) are still unclear, especially in China. Information on these aspects cannot be accurately obtained due to the death of perpetrators. This study aims to demonstrate the characteristics of incomplete H-S with surviving perpetrators, which provide the possibility to obtain detailed mental and psychological information.

METHODS

This study explores incomplete H-S events occurred in Hunan, China from 2010 to 2019, in which the surviving perpetrators received a forensic psychiatric assessment. Three aspects of information, i.e., the subject's demographic, clinical and criminal information, were recorded and analysed.

RESULTS

125 incomplete H-S incidents involved 166 victims were found in the current study. A total of 112 (89.6%) perpetrators were diagnosed with mental disorders, but only 56 of them had a history of consultation due to mental problems, and only one of them adhered to treatment. In most cases, the motivation is related to the psychopathological states, with the most common diagnosis being major depression, followed by schizophrenia. Gender difference was significant among the subjects: females were more likely to have a suicidal history, to be diagnosed as major depression and to be motivated by delirious altruism and family problems.

CONCLUSIONS

This study indicated that psychopathology might be a predisposing factor, which highlighted the importance of mental state assessment for the population involved in incomplete H-S. A clearer understanding of the role of mental disorders might be helpful for the intervention of H-S.

Motivational Influences and Trajectories to Violence in the Context of Major Mental Illness

Developmental trajectories regarding the age onset of violence and offending have not routinely considered the role of major mental illness (MMI). In parallel, despite several studies investigating the relationship between MMI, violence and offending, fewer have identified motivational processes that may link illness to these outcomes in a more direct and proximal manner. This study investigates whether subtypes of forensic psychiatric patients deemed Not Criminally Responsible on account of Mental Disorder (N = 91) can be identified based on the age onset of mental illness and offending behavior, and whether information on motivational influences for offending-elicited both from the patient directly and detailed collateral information-contributes to the clinical utility of this typology. Results indicated that most patients reported engaging in violence (51%) or antisocial behaviors (72%) prior to the onset of MMI, but that the index offense(s) resulting in forensic admission were predominantly psychotically motivated. In contrast to patients for whom the onset of MMI occurred prior to offending, patients exhibiting premorbid violence had higher levels of risk and criminogenic need; they were more likely to be diagnosed with personality and substance use disorders, and to have conventional (i.e., non-illness-related) motivations ascribed to their index offense. Findings are consistent with the existing literature regarding subgroups of mentally disordered offenders, but provide new information regarding proximal risk factors for violence through better identification of motivational processes.

A rare case of complete male genital self-amputation posing challenges in the psychiatric diagnosis and management

Genital self-mutilation (GSM) is a rare phenomenon encountered mostly within the context of severe mental illness. The following case report highlights a rare case of self-inflicted total penile self-amputation in a patient with a psychiatric history of polydrug abuse and attention deficit disorder (ADD). The patient engaged in penile self-amputation under the influence of command hallucinations and religious delusions. He was operated on with microsurgical penile replantation but the penis had to be amputated after two weeks because of postoperative complications. The patient was admitted for compulsory psychiatric treatment. During the prolonged hospitalization course, he was arrested for stabbing two other patients and was transferred to a forensic psychiatric unit. The case fits the description for Klingsor Syndrome and involved multiple interacting risk factors that complicated the initial presentation and the ensuing management of the condition in the hospital setting.

Preserved intention understanding during moral judgments in schizophrenia

INTRODUCTION

Although there is convincing evidence for socio-cognitive impairments in schizophrenia spectrum disorder (SSD), little evidence is found for deficient moral cognition. We investigated whether patients with SSD showed altered moral judgments in a story task where the protagonist either had a neutral or malicious intention towards another person. This paradigm examined whether SSD relates to altered moral cognition in general or specifically to impaired integration of prior information (such as beliefs) in moral judgments.

METHODS

23 patients and 32 healthy controls read vignettes created in a 2 x 2 design. The protagonist in each story either had a neutral or negative intention towards another person which, as a result, either died (negative outcome) or did not die (neutral outcome). Participants rated the moral permissibility of the protagonist's action. Standard null hypothesis significance testing and equivalent Bayes analyses are reported.

RESULTS

Schizophrenia patients did not differ significantly in permissibility ratings from healthy controls. This finding was supported by the Bayes analyses which favoured the null hypothesis. Task performance was not related to symptom severity or medication.

CONCLUSIONS

The current findings do not support the notion that moral judgments are deficient in schizophrenia. Furthermore, the current study shows that patients do not have observable difficulties in integrating the protagonist's belief in the rating of the moral permissibility of the action-outcome.

Forensic psychiatric evaluation of 187 homicidal assailants with and without a schizophrenia spectrum disorder: Clinical, criminological and behavioral characteristics

Intentional homicide, a declining phenomenon in Italy, represents one of the most extreme forms of violence. A specific subgroup of homicidal assailants is represented by those affected by mental disorders, where the relationship between psychopathology and characteristics of the homicidal attack is not yet fully understood. We analyzed the case files of 187 homicides or attempted homicides, in which the defendant had undergone a forensic psychiatric evaluation within the previous 10 years from a single forensic psychiatric center. We described and analyzed the perpetrator, victim and criminological characteristics of the study cases. A diagnosis of a schizophrenia spectrum disorder, a victim who was the perpetrator's biological child and absence of a personality disorder diagnosis were associated with an increased probability of having been adjudicated as lacking or having substantially diminished criminal responsibility due to a mental disorder. Homicidal assailants with a schizophrenia spectrum disorder showed some differences in criminological characteristics compared with murderers without a schizophrenic spectrum disorder, including a higher incidence of parricide, interruption of pharmacotherapy before the crime and disorganized post-crime behavior.

[Differential diagnostic distinction between substance-induced and primary psychoses: : Recommendations for general psychiatric and forensic practice]

Substanzinduzierte psychotische Störungen (SIPS) sind häufig und für ca. 25 % der ersten Einweisungen in eine psychiatrische Klinik verantwortlich. Aus klinischer Sicht ist aufgrund ähnlicher psychopathologischer Phänomene die diagnostische Unterscheidung zwischen SIPS und primären (genuinen oder kryptogenen) psychotischen Störungen oft eine Herausforderung. Dieser Umstand wird dadurch erschwert, dass SIPS im Zusammenhang mit Cannabis, Halluzinogenen und Amphetaminen ein erhebliches Risiko des Übergangs in eine primäre psychotische Störung (z. B. Schizophrenie) haben. Im ersten Abschnitt dieser Arbeit werden zunächst zwei exemplarische Fallvignetten aus der allgemeinpsychiatrischen und forensischen Praxis vorgestellt. Danach wird im Sinne einer selektiven Literaturübersicht die Relevanz der differenzialdiagnostischen Unterscheidung beider Störungsbilder aus der Sicht der allgemeinen und forensischen Psychiatrie in Bezug auf Therapie, Prognose und richterliche Entscheidung bezüglich der Unterbringung im Maßregelvollzug (§ 63 vs. § 64 StGB) beleuchtet. Der letzte Abschnitt hat das Ziel, ein strukturiertes Vorgehen zur differenzialdiagnostischen Unterscheidung zwischen SIPS und primären psychotischen Störungen zu erarbeiten. Die in dieser Arbeit dargestellten und diskutierten Konzepte und Befunde sollen klinisch tätigen Psychiatern und Psychologen die Diagnosestellung im allgemeinen und forensischen Kontext erleichtern.

Research findings on Greek forensic patients found not guilty by reason of insanity. A juxtaposition of patients who committed a criminal offense during their first psychotic episode with those who did so later in the course of their illness

The aim of this study was to compare the baseline characteristics (demographic, psychiatric-psychopathological and legal) among Greek forensic patients found not guilty by reason of insanity. The first step of this approach being differentiating patients who committed a criminal offense during their first psychotic episode from the ones who did so later in the course of their illness. All patients were hospitalized in the Department of Forensic Psychiatry (DFP) of the Psychiatric Hospital of Thessaloniki (PHT) from January 2015 to January 2020 and were examined in order to be included in the study. The final research sample consisted of 78 patients (70 identifying themselves as males and 8 identifying themselves as females) aged 18 and older, 21 of whom committed a criminal offense during their first psychotic episode (FEP, N = 21) and 57 did so later on in the course of their illness (Course, N = 57). Data were collected from multiple sources and several psychometric tools were used (Mini International Neuropsychiatric Interview-M.I.N·I, Positive And Negative Syndrome Scale-PANSS, Addiction Severity Index-ASI, CAGE Questionnaire, Hostility and Direction of Hostility Questionnaire-HDHQ, Global Assessment of Functioning-GAF and Aggression Questionnaire). Comparing the two groups (FEP vs. Course) we found that patients in FEP were younger, had experienced stressful life events in the last 24 months, committed more serious violent crimes, and more frequently attempted suicide after the crime. Their victims were usually members of their family. The main psychometric disparities between the two groups were found in the "Hostility" score of the Aggression questionnaire, and the items "Criticism of Others" and "Paranoid Hostility" of the HDHQ questionnaire, where patients in FEP scored lower. Patients in FEP scored significantly higher in items P1 (delusions), P4 (excitement), P6 (suspiciousness/persecution) and P7 (hostility) of the PANSS scale. No statistically significant differences were found between the two groups regarding their evaluation with the CAGE, ASI or GAF questionnaires. When comparing the patients' present scores in PANSS scale, the patients in FEP had lower total scores in the Positive and the General Psychopathology subscales. Both groups showed significant improvement during hospitalization in all scales (PANSS & GAF), except for the Negative Subscale of the PANSS scale. Through logistic regression analysis, we found that patients in FEP were younger, more likely to have recently experienced stressful life events and more likely to have assaulted a member of their family. Patients with higher scores in the "Hostility" subscale of the Aggression questionnaire were found to remain at risk for committing a crime during the course of their illness. These findings underline the need to design and develop specialized mental health services in order to identify and treat patients involved in violent crime in a timely and effective manner addressing their multiple needs.

Violence and mental disorders: a structured review of associations by individual diagnoses, risk factors, and risk assessment

In this Review, we summarise evidence on the association between different mental disorders and violence, with emphasis on high quality designs and replicated findings. Relative risks are typically increased for all violent outcomes in most diagnosed psychiatric disorders compared with people without psychiatric disorders, with increased odds in the range of 2-4 after adjustment for familial and other sources of confounding. Absolute rates of violent crime over 5-10 years are typically below 5% in people with mental illness (excluding personality disorders, schizophrenia, and substance misuse), which increases to 6-10% in personality disorders and schizophrenia spectrum disorders, and to more than 10% in substance misuse. Past criminality and comorbid substance misuse are strongly predictive of future violence in many individual disorders. We reviewed national clinical practice guidelines, which vary in content and require updating to reflect the present epidemiological evidence. Standardised and clinically feasible approaches to the assessment and management of violence risk in general psychiatric settings need to be developed.

The HCR-20 and violence risk assessment - will a peak of inflated expectations turn to a trough of disillusionment?

The HCR-20 has taken on a life of its own. In forensic services it has been elevated from helpful aide-mémoire into a prophetic tool worthy of Nostradamus himself. Almost every outcome is interpreted through it. Despite the evidence of its limited utility, the difficulties of predicting rare events, the narrative fallacies and other heuristic biases it creates, and the massive opportunity costs it entails, commissioners and services alike mandate its use. Yet in routine practice the problems are not acknowledged, multiple conflicts of interest lie unobserved and other opportunities are neglected.

Decriminalizing severe mental illness by reducing risk of contact with the criminal justice system, including for forensic patients

Risk of contact with the criminal justice system (CJS) is greater among those with mental illness, including severe mental illness-an observation that many argue reflects a process of "criminalizing" mental illness. Forensic patients represent a subgroup at one end of a spectrum of such criminalization, typically with histories of serious violence and psychotic illness. Strategies for decriminalizing mental illness in this context should consider a range of approaches, including intervening to prevent CJS contact in those with severe mental illness, particularly in the early or emerging stages of psychosis. However, it may be that even gold standard mental healthcare applied universally is insufficient to address CJS contact risks. While there is now an extensive literature documenting the relatively low rates of repeat CJS contact for forensic patients released from secure care, appropriate comparison groups are lacking and the key ingredients of any benefits of treatment are unknown. The CJS may well have something to learn from forensic mental health systems and services given the abject failure to stem rates of prison-release reoffending internationally. Understanding how to best identify risk and effectively intervene to prevent CJS contact in those with mental illness, whether early in the course of psychosis or following release from secure care, remains a priority for those seeking to address the criminalization of mentally illness in our communities.

Homicide committed by individuals with severe mental illnesses: A comparative study before and after the Tunisian revolution of January 14th, 2011

BACKGROUND

Many studies have established a correlation between the increase of homicide rates, and economic crises and rapid social changes following historical events. We propose to analyse the impact of the Tunisian Revolution on homicide rates in Tunisia in a clinical population.

METHODS

We conducted a retrospective comparative study of all individuals who commited an homicide and were admitted, at least once, to the forensic psychiatry unit in Razi Hospital between January 1st, 2004 and December 31st, 2018 after a decision of irresponsibility by reason of insanity.

RESULTS

The number of homicides committed by the individuals with mental illness included in our study was multiplied by a factor of 1.3 after the revolution, with a prevalence of 11.0% between 2004 and 2011, compared to a prevalence of 14.7% during the period 2011-2018. No significant difference was noted between the two groups regarding the socio-demographic characteristics or the characteristics of the act committed.

CONCLUSION

Our results highlighted that political and socio-economic crises following the Tunisian revolution significantly contributed to an increase of homicide rates in people with severe mental illness. Thus, macro-level socioeconomic determinants would be important to consider in homicide prevention strategies.

A meta-analysis of the relationship between psychosis and any type of criminal offending, in both men and women

BACKGROUND

Psychosis is known to be associated with an increased risk of violent offending, but the risk of criminal offending of any type is not so well understood, including the nature and extent of any differences in offending risk for men and women with psychosis.

METHODS

A systematic search of electronic databases from 1970 to March 2020 was conducted to identify studies comparing criminal offending amongst those with psychosis to a general population sample. A meta-analysis was performed, with separate analyses undertaken for men and women.

RESULTS

Eight studies, with a total of 15,446 individuals with psychosis and 186,752 controls from general population sources, met our inclusion criteria. The pooled odds ratio for any type of criminal offending for men with psychosis was 2.42 (95% CI = 1.63-3.59), and for women it was 2.81 (95% CI = 2.11-3.76). Substantial between study heterogeneity was identified.

CONCLUSIONS

Although the pooled odds ratio for all types of offending was not as high as has been found for violence, those with psychotic illness were more than twice as likely to have had contact with the criminal justice system for any type of criminal offence, compared to the general population. Little difference in risk was seen for women compared to men with psychosis. Clinical risk assessments and the development of interventions to reduce risk of contact with the criminal justice system should consider that risk of offending for those with psychosis extends right across the spectrum of offence types.

Specialized assertive community treatment intervention for homeless youth with first episode psychosis and substance use disorder: A 2-year follow-up study

AIM

No previous study has investigated interventions for homeless youth suffering from first episode psychosis and comorbid substance use disorder (HYPS). An intensive assertive community intervention team (IACIT) offering outreach interventions, housing support as well as integrated care for early psychosis and substance use disorder (SUD) was created in 2012 at the Centre Hospitalier de l'Université de Montréal (CHUM). To explore the impact of the addition of an IACIT to an early intervention for psychosis service (EIS) on housing stability, functional and symptomatic outcomes and mental health service use.

METHODS

A two-year longitudinal study comparing the outcome of HYPS receiving combined EIS and IACIT since 2012, to a historical cohort of HYPS receiving EIS only between 2005 and 2011. Socio-demographic data, housing stability, functioning, illness severity, SUD severity, emergency room visits and hospitalizations were assessed at admission, at 1 month, and every 3 months thereafter.

RESULTS

HYPS receiving EIS + IACIT achieved housing stability more rapidly and spent less time hospitalized than HYPS getting EIS only (RR 2.38, P = .017). HYPS with cocaine misuse were less likely to attain housing stability (RR 0.25, P = .04). No between-group differences were found for psychiatric symptoms, functioning and SUD outcomes.

CONCLUSION

The addition of IACIT-HYPS to EIS was associated with earlier housing stability and reduced total hospitalization days compared to EIS alone.

Evidence-based guidelines for the pharmacological treatment of schizophrenia: Updated recommendations from the British Association for Psychopharmacology

These updated guidelines from the British Association for Psychopharmacology replace the original version published in 2011. They address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting was held in 2017, involving experts in schizophrenia and its treatment. They were asked to review key areas and consider the strength of the evidence on the risk-benefit balance of pharmacological interventions and the clinical implications, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. The guidelines cover the pharmacological management and treatment of schizophrenia across the various stages of the illness, including first-episode, relapse prevention, and illness that has proved refractory to standard treatment. It is hoped that the practice recommendations presented will support clinical decision making for practitioners, serve as a source of information for patients and carers, and inform quality improvement.

Impulsivity in early psychosis: A complex link with violent behaviour and a target for intervention

Background

Violent behaviour (VB) occurs in first episode of schizophrenia and can have devastating impact both on victims and patients themselves. A better knowledge of the underlying mechanisms of VB may pave the way to preventive treatments.

Objectives

1) To explore the nature of the link between impulsivity and VB in early psychosis (EP) patients; 2) To explore the interactions between impulsivity and substance abuse, insight, and positive symptoms, the main dynamic risk factors of VB described to date.

Design and methods

Post hoc analysis of data acquired in the frame of a 36-months EP cohort study. A total of 265 EP patients, aged 18 to 35, treated at TIPP (Treatment and early Intervention in Psychosis Program), at the Department of Psychiatry in Lausanne, Switzerland, were included in the study. Logistic regression analyzes were performed as well as mediation analysis and interaction analysis

Results

Our data suggest that impulsivity is a predictor of VB when analyzed independently and as part of a multi-factorial model. Impulsivity continues to differentiate violent patients from non-violent ones at the end of the program. In addition, the relationship between impulsivity and VB is not mediated by substance abuse. Finally, the effect of impulsivity on the probability of VB is potentiated by the interaction of different levels of insight and positive symptoms.

Conclusions

Early intervention strategies in psychotic disorders should include evaluation of impulsivity considering it is linked to increased risk of VB and may respond to treatment.

Moral cognition, the missing link between psychotic symptoms and acts of violence: a cross-sectional national forensic cohort study

BACKGROUND

People with schizophrenia are ten times more likely to commit homicide than a member of the general population. The relationship between symptoms of schizophrenia and acts of violence is unclear. There has also been limited research on what determines the seriousness and form of violence, such as reactive or instrumental violence. Moral cognition may play a paradoxical role in acts of violence for people with schizophrenia. Thoughts which have moral content arising from psychotic symptoms may be a cause of serious violence.

METHOD

We investigated if psychotic symptoms and moral cognitions at the time of a violent act were associated with acts of violence using a cross-sectional national forensic cohort (n = 55). We examined whether moral cognitions were associated with violence when controlling for neurocognition and violence proneness. We explored the association between all psychotic symptoms present at the time of the violent act, psychotic symptoms judged relevant to the violent act and moral cognitions present at that time. Using mediation analysis, we examined whether moral cognitions were the missing link between symptoms and the relevance of symptoms for violence. We also investigated if specific moral cognitions mediated the relationship between specific psychotic symptoms, the seriousness of violence (including homicide), and the form of violence.

RESULTS

Psychotic symptoms generally were not associated with the seriousness or form of violence. However, specific moral cognitions were associated with the seriousness and form of violence even when controlling for neurocognition and violence proneness. Specific moral cognitions were associated with specific psychotic symptoms present and relevant to violence. Moral cognitions mediated the relationship between the presence of specific psychotic symptoms and their relevance for violence, homicide, seriousness of violence, and the form of violence.

CONCLUSIONS

Moral cognitions including the need to reduce suffering, responding to an act of injustice or betrayal, the desire to comply with authority, or the wish to punish impure or disgusting behaviour, may be a key mediator explaining the relationship between psychotic symptoms and acts of violence. Our findings may have important implications for risk assessment, treatment and violence prevention.

Applying economic models to estimate local economic benefits of improved coverage of early intervention for psychosis

AIM

Early Intervention Psychosis Services (EIPS) for people experiencing First Episode Psychosis (FEP) offer important clinical and non-clinical benefits over standard care. Similarly, intervention for Clinical High Risk for Psychosis state (CHR-P) can prevent psychosis, ameliorate symptoms and have non-clinical benefits. This study aimed to estimate associated local economic benefits of FEP and CHR-P services compared with standard care.

METHODS

Across four south London boroughs, proportion of annual number of new cases of FEP and CHR-P seen by early intervention services was estimated. Economic modelling conducted for England's mental health strategy was applied to estimate local economic impacts of current and improved service provision.

RESULTS

Across four London boroughs during 2011/2012, proportion of 15-34 year olds with FEP seen by EIPS was 100.2% assuming 80/100 000 annual incidence whereas proportion with CHR-P seen by CHR-P services was 4.1% assuming 200/100 000 annual incidence. Application of economic modelling suggests that provision of EIPS to reach all new FEP cases each year would free up resources of £13.1m over 10 years including £2.0m to National Health Service (NHS) after the first year. Scaling up to reach all new CHR-P cases each year would free up resources of £19.7m over 10 years with an estimated 10-year cost of implementation gap for each 1 year cohort of £18.9m. An earlier related briefing resulted in increased funding for EIPS and new CHR-P services despite overall cuts to mental health services.

CONCLUSIONS

Estimation of local economic impacts of FEP and CHR-P services was associated with improved investment in such services.