Substance abuse as a risk factor for violence in mental illness: some implications for forensic psychiatric practice and clinical ethics

Neurofeedback and meditation technology in outpatient offender treatment: a feasibility and usability pilot study

Introduction

Although Cognitive Behavioral Therapy (CBT) is the most often used intervention in forensic treatment, its effectivity is not consistently supported. Interventions incorporating knowledge from neuroscience could provide for more successful intervention methods.

Methods

The current pilot study set out to assess the feasibility and usability of the study protocol of a 4-week neuromeditation training in adult forensic outpatients with impulse control problems. The neuromeditation training, which prompts awareness and control over brain states of restlessness with EEG neurofeedback, was offered in addition to treatment as usual (predominantly CBT).

Results

Eight patients completed the neuromeditation training under guidance of their therapists. Despite some emerging obstacles, overall, the training was rated sufficiently usable and feasible by patients and their therapists.

Discussion

The provided suggestions for improvement can be used to implement the intervention in treatment and set up future trials to study the effectiveness of neuromeditation in offender treatment.

Substance Use Disorder and Violence Among People with Severe Mental Illness in the United States

In studying substance use disorder (SUD) and violence in severe mental illness (SMI), researchers account for presence of SUD or addictions to specific substances. However these studies fail to comprehensively capture solitary drug use versus specific combinations in a single exhaustive variable with more nuance (e.g., opioids only, alcohol only, both alcohol and opioids only, and so on). Using logistic regression to predict past-year violence, this study compared conventional SUD measurement (Model I: presence versus absence of SUD or specific SUDS) to a newer and more holistic approach (Model II: a single exhaustive variable with both solitary addictions [e.g., opioids only] and specific combinations of addictions [e.g., both opioids and alcohol only]) among 10,551 people with SMI in the National Survey of Drug Use and Health (20,015 - 2019). After adjusting for a wide variety of factors in Model II, people with (1) alcohol use disorders only were 2.24 times more likely to be violent (CI = 1.46-3.45, p <.001); (2) opioid use disorders only were 3.45 times more likely (CI-1.48-8.05, p,>01); (3) both alcohol and cocaine use disorders or cocaine only were 5.85 times more likely (CI = 2.63-13.05, p <.001); and (4) both alcohol and opioid use disorders only were 4.28 times more likely (CI = 1.34-13.71, p <.05). These more nuanced findings in Model II differed substantially from those using conventional SUD assessment in Model I, and the newer and more holistic approach can better reflect the complexity of addiction in relation to violence in SMI. Therefore studies, practices, and policies that address SUD and violence in SMI could be beneficially revisited with this greater comprehensiveness and detail.

A latent class analysis of mental disorders, substance use, and aggressive antisocial behavior among Swedish forensic psychiatric patients

BACKGROUND

Patients in the forensic mental health services (FMHS) with a mental disorder, a co-occurring substance use disorder (SUD), and high risk of aggressive antisocial behavior (AAB) are sometimes referred to as the 'triply troubled'. They suffer poor treatment outcomes, high rates of criminal recidivism, and increased risk of drug related mortality. To improve treatment for this heterogeneous patient group, more insight is needed concerning their co-occurring mental disorders, types of substances used, and the consequent risk of AAB.

METHODS

A three-step latent class analysis (LCA) was used to identify clinically relevant subgroups in a sample of patients (n = 98) from a high-security FMHS clinic in Sweden based on patterns in their history of mental disorders, SUD, types of substances used, and AAB.

RESULTS

A four-class model best fit our data: class 1 (42%) had a high probability of SUD, psychosis, and having used all substances; class 2 (26%) had a high probability of psychosis and cannabis use; class 3 (22%) had a high probability of autism and no substance use; and class 4 (10%) had a high probability of personality disorders and having used all substances. Both polysubstance classes (1 and 4) had a significantly more extensive history of AAB compared to classes 2 and 3. Class 3 and class 4 had extensive histories of self-directed aggression.

CONCLUSIONS

The present study helps disentangle the heterogeneity of the 'triply troubled' patient group in FMHS. The results provide an illustration of a more person-oriented perspective on patient comorbidity and types of substances used which could benefit clinical assessment, treatment planning, and risk-management among patients in forensic psychiatric care.

The curse of experiencing and committing violence as a criminal recidivism predictor: A comparison between female forensic psychiatric patients with severe mental disorders and substance use disorder

BACKGROUND

Violence occurs frequently in the life of forensic psychiatric patients, both as active aggression and in the form of victimization. Undoubtedly, these incidents shape personality, behavior, and affect the ability to interact adequately socially. Thus, such experiences may influence criminal recidivism and serve as forensic psychiatric/psychological predictors upon hospital discharge.

METHODS

Hence, this study aimed at characterizing two distinct female forensic psychiatric patient populations (nonsubstance use mental disorders [n = 110] versus substance use disorder [n = 415]) regarding their active and passive violent experiences as well as contextualizing these with their individual crime recidivism rates. The analysis followed a record-based, retrospective approach.

RESULTS

While both groups experienced aggression throughout childhood and youth equally often, substance use disorder patients were significantly more often exposed to violence during adulthood. On the other hand, severely mentally ill patients tended to react more often with violence during their hospital confinement. However, regarding their violent recidivism rate, no intergroup effects were observed. Finally, within the addicted group, a violent index crime as well as physical aggression during hospital confinement increased the odds for violent reoffending by approximately 2.4-fold (95% confidence interval 1.3-4.5) and 2.5-fold (95% confidence interval 1.1-5.9), respectively.

CONCLUSION

In summary, these findings underline the importance of active aggression rather than victimization as an influencing factor on resocialization especially in a substance use disorder patient population.

The effect of cocaine on patients undergoing total hip arthroplasty

Background

Cocaine use has surged in the past decade, with 4.8 million Americans (1.7% of the population greater than 12) reporting use in 2021, leading to a healthcare burden of 1.3 billion dollars. Cocaine users experience prolonged hospital stays, higher costs, worse surgical outcomes, increased risk of medical conditions, and inflammation-related osteoarthritis. The study aims to identify factors influencing length of stay, costs, and perioperative complications in cocaine users undergoing total hip arthroplasty (THA) to reduce these risks.

Methods

This study utilized the NIS database, providing comprehensive information on patient demographics, length of stay, hospital costs, and complications. Statistical analyses were conducted using SPSS software, including propensity matching and significance testing, to compare outcomes between cocaine users (CU) and non-cocaine users (NCU) undergoing total hip arthroplasty.

Results

After propensity matching, cocaine users had a significantly longer LOS (4.8 days) in comparison to non-cocaine users (2.6 days) (p < 0.001). Similarly, the CU group had a larger of care (87984.9) than the NCU group (69149.2) (p < 0.001). Cocaine users had significantly higher rates of blood loss anemia (OR: 3.24, 95% CI: 2.21, 4.73), blood loss anemia (OR: 1.59, 95% CI: 1.12, 2.24), blood transfusion (OR: 2.23, 95% CI: 1.04, 4.78), periprosthetic dislocation (OR: 6.57, 95% CI: 1.47, 29.32), and periprosthetic infection (OR: 4.59, 95% CI: 1.54, 13.68) than patients in the non-cocaine user's group.

Conclusion

Cocaine users had a significantly longer length of stay, higher costs of care, and an increased number of post-operative complications compared to non-cocaine users. These data contribute to understanding the potential ramifications of cocaine users undergoing THA.

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

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Association Between Cannabis and Violence in Community-Dwelling Patients With Severe Mental Disorders: A Cross-sectional Study Using Machine Learning

The objective of this cross-sectional study was to identify cannabis-related features and other characteristics predictive of violence using a data-driven approach in patients with severe mental disorders (SMDs). A Least Absolute Shrinkage and Selection Operator regularization regression model was used on the database consisting of 97 patients with SMD who completed questionnaires measuring substance use and violence. Cannabis use, particularly related to patients' decision to consume or time spent using, was a key predictor associated with violence. Other patterns of substance use and personality traits were identified as strong predictors. Regular patterns of cannabis use and interpersonal issues related to cannabis/stimulant abuse were inversely correlated to violence. This study identified the effect of several predictors correlated to violence in patients with SMD using a regularization regression model. Findings open the door to better identify the profiles of patients that may be more susceptible to perpetrate violent behaviors.

Associations Between Adverse Childhood Experiences and Tobacco, Alcohol, and Drug Use Among Individuals with Serious Mental Illnesses in Public-Sector Treatment Settings

Adverse childhood experiences (ACEs) increase risk of substance use disorders (SUDs). Little research has focused on individuals with serious mental illnesses (SMI), despite their high prevalence of both ACEs and SUDs. We combined two datasets from prior studies (n = 299 and n = 240, total n = 539) that measured ACEs and made research diagnoses for SUDs. When controlling for other variables-age, gender, race, diagnostic category (psychotic disorder versus mood disorder), and study site (Washington, DC-area versus southeast Georgia)- in logistic regression models, ACE score was associated with tobacco use, presence of any SUD, alcohol use disorder, cannabis use disorder, and cocaine use disorder. Each one-unit increase in the ACE score increased the odds of SUD-related outcomes by 9-18%. Clinicians, program planners, and researchers should be aware of the powerful and long-lasting impact of ACEs, and the need for thorough screening and assessment of both SUDs and ACEs among patients with SMI.

Drug-Free Community Support in Inpatients with Co-occurring Psychiatric Disorders and Substance Use Problems

Objective: This study evaluated the presence of drug-free family and friends in the social networks of patients treated in an inpatient setting for co-occurring psychiatric disorders and substance use problems. Methods: Social network interviews were conducted with inpatients at the Johns Hopkins Bayview Acute Psychiatric Unit with co-occurring psychiatric disorders and substance use problems (N = 90). Results: Participants reported about five social network members, of which four were drug-free. Most participants (> 70%) were willing to include a drug-free person in the current inpatient treatment plan to support recovery efforts (M = 1.8 network members) and identified several areas of recovery support. Conclusions: These results demonstrate that people treated in an inpatient psychiatric setting have local drug-free family or friends that they are willing to include in the treatment process. These findings support further study of methods to mobilize network members to enhance social support during and following hospitalization.

Prediction of reoffending risk in men convicted of sexual offences: development and validation of novel and scalable risk assessment tools (OxRIS)

BACKGROUND

Current risk assessment tools have a limited evidence base with few validations, poor reporting of outcomes, and rarely include modifiable factors.

METHODS

We examined a national cohort of men convicted of sexual crimes in Sweden. We developed prediction models for three outcomes: violent (including sexual), any, and sexual reoffending. We used Cox proportional hazard regression to develop multivariable prediction models and validated these in an external sample. We reported discrimination and calibration statistics at prespecified cut-offs.

FINDINGS

We identified 16,231 men convicted of sexual offences, of whom 14.8% violently reoffended during a mean follow up of 38 months, 31.4% for any crime (34 months), and 3.6% for sexual crimes (42 months). Models for violent and any reoffending showed good discrimination and calibration. At 1, 3, and 5 years, the area under the curve (AUC) was 0.75-0.76 for violent reoffending and 0.74-0.75 for any reoffending. The prediction model for sexual reoffending showed modest discrimination (AUC = 0.67) and good calibration. We have generated three simple and web-based risk calculators, which are freely available.

INTERPRETATION

Scalable evidence-based risk assessment tools for sexual offenders in the criminal justice system and forensic mental health could assist decision-making and treatment allocation by identifying those at higher risk, and screening out low risk persons.

Exploring substance use as rule-violating behaviour during inpatient treatment of offender patients with schizophrenia

BACKGROUND

Rule-violating behaviour in the form of substance misuse has been studied primarily within the context of prison settings, but not in forensic psychiatric settings.

AIMS

Our aim was to explore factors that are associated with substance misuse during hospitalisation in patients among those patients in a Swiss forensic psychiatric inpatient unit who were suffering from a disorder along the schizophrenia spectrum.

METHODS

From a database of demographic, clinical and offending data on all residents at any time between 1982 and 2016 in the forensic psychiatric hospital in Zurich, 364 cases fulfilled diagnostic criteria for schizophrenia or a schizophrenia-like illness and formed our sample. Any confirmed use of alcohol or illicit substances during admission (yes/no) was the dependent variable. Its relationship to all 507 other variables was explored by machine learning. To counteract overfitting, data were divided into training and validation set. The best model from the training set was tested on the validation set.

RESULTS

Substance use as a secure hospital inpatient was unusual (15, 14%). Prior substance use disorder accounted for so much of the variance (AUC 0.92) that it was noted but excluded from further models. In the resulting model of best fit, variables related to rule breaking, younger age overall and at onset of schizophrenia and nature of offending behaviour, substance misuse as a minor and having records of complications in prior psychiatric treatment were associated with substance misuse during hospitalisation, as was length of inpatient treatment. In the initial model the AUC was 0.92. Even after removal of substance use disorder from the final model, performance indicators were meaningful with a balanced accuracy of 67.95, an AUC of 0.735, a sensitivity of 81.48% and a specificity of 57.58%.

CONCLUSIONS

Substance misuse in secure forensic psychiatric hospitals is unusual but worthy of clinical and research consideration because of its association with other rule violations and longer hospitalisation. More knowledge is needed about effective interventions and rehabilitation for this group.

Towards a More Evidence-Based Risk Assessment for People in the Criminal Justice System: the Case of OxRec in the Netherlands

Risk assessment tools are widely used throughout the criminal justice system to assist in making decisions about sentencing, supervision, and treatment. In this article, we discuss several methodological and practical limitations associated with risk assessment tools currently in use. These include variable predictive performance due to the exclusion of important background predictors; high costs, including the need for regular staff training, in order to use many tools; development of tools using suboptimal methods and poor transparency in how they create risk scores; included risk factors being based on dated evidence; and ethical concerns highlighted by legal scholars and criminologists, such as embedding systemic biases and uncertainty about how these tools influence judicial decisions. We discuss the potential that specific predictors, such as living in a deprived neighbourhood, may indirectly select for individuals in racial or ethnic minority groups. To demonstrate how these limitations and ethical concerns can be addressed, we present the example of OxRec, a risk assessment tool used to predict recidivism for individuals in the criminal justice system. OxRec was developed in Sweden and has been externally validated in Sweden and the Netherlands. The advantages of OxRec include its predictive accuracy based on rigorous multivariable testing of predictors, transparent reporting of results and the final model (including how the probability score is derived), scoring simplicity (i.e. without the need for additional interview), and the reporting of a wide range of performance measures, including those of discrimination and calibration, the latter of which is rarely reported but a key metric. OxRec is intended to be used alongside professional judgement, as a support for decision-making, and its performance measures need to be interpreted in this light. The reported calibration of the tool in external samples clearly suggests no systematic overestimation of risk, including in large subgroups.

Investigating factors associated with the number of rehospitalizations among patients with schizophrenia disorder using penalized count regression models

BACKGROUND

Schizophrenia is a chronic, severe, and debilitating mental disorder always considered one of the recurrent psychiatric diseases. This study aimed to use penalized count regression models to determine factors associated with the number of rehospitalizations of schizophrenia disorder.

METHODS

This retrospective cohort study was performed on 413 schizophrenic patients who had been referred to the Sina (Farshchian) Educational and Medical Center in Hamadan, Iran, between March 2011 and March 2019. The penalized count regression models were fitted using R.3.5.2.

RESULTS

About 73% of the patients were male. The mean (SD) of age and the number of rehospitalizations were 36.16 (11.18) years and 1.21 (2.18), respectively. According to the results, longer duration of illness (P < 0.001), having a positive family history of psychiatric illness (P = 0.017), having at least three children (P = 0.013), unemployment, disability, and retirement (P = 0.025), residence in other Hamadan province townships (P = 0.003) and having a history of arrest/prison (P = 0.022) were significantly associated with an increase in the number of rehospitalizations.

CONCLUSION

To reduce the number of rehospitalizations among schizophrenic patients, it is recommended to provide special medical services for patients who do not have access to specialized medical centers and to create the necessary infrastructure for the employment of patients.

The phenomenon of overkill in northern Greece: A descriptive forensic psychiatric study between 2015 and 2020 on criminal offenders found not guilty by reason of insanity

The purpose of this descriptive study was to investigate overkill in a representative sample of Greek psychiatric patients found not guilty by reason of insanity (NGRIs) from a forensic psychiatric - criminological standpoint and explore possible correlations of the phenomenon with socio-cultural or psychiatric factors. Overall, 24 forensic psychiatric records of overkill offenders were identified throughout the 5-year records of the national forensic psychiatric service in northern Greek mainland. The pattern that has emerged from the statistical results of the present study on the victims of overkill within the Greek borders was generally in line with global literature on homicide perpetrators. The mean age of overkill offenders (at the time of enactment of the crime) was estimated at 36.3 years ranging from 19 to 55 years (variance = 146.72; standard deviation = 12.11). The number of male single-offence killers was ten-times larger compared to their female counterparts, while the number of male multiple-offence killers were three-times larger compared to their female counterparts. Male offenders were averagely 15 years younger (mean 33.7; variance = 81.69; standard deviation = 9) in comparison to female offenders, and single-offence killers were averagely ten years younger compared to multiple-offence killers (mean 40.2; variance = 185.19; standard deviation = 13.6). The phenomenon correlated more strongly with homicides in the context of schizophrenia spectrum disorders (80-100%) as well as domestic violence. Overall, males outnumbered females both as offenders (approximately five-times) and victims (approximately three-times), but regarding domestic violence, the sad majority of overkill victims stood for females murdered by their male relatives. Close female relatives (especially mothers and grandmothers) were most often victimized. Female-perpetrated overkill was directed against male individuals with whom offenders shared a relationship (intimate partners and minors). An important finding was the fact that three-quarters of the overall perpetrator sample were under prescribed medication at the time of offence, but with a very low compliance rate (5.6%). This last particular finding of the present study demonstrated that mental health services within community in Greece may unfortunately have been ineffective in addressing issues requiring risk assessment and timely intervention.

Patient outcomes in an Australian low secure forensic psychiatric rehabilitation inpatient unit: a 10-year retrospective study

The aim of this study is to investigate the background and discharge outcomes of the forensic patient population rehabilitated through a low secure forensic psychiatric rehabilitation inpatient unit. Currently within Australia and internationally there is a scarcity of research completed within this setting. A quantitative methodology was selected coupled with descriptive statistics to investigate a total of 23 patients and analyse their demographics, historical information, length of stay and post-discharge outcomes including readmission and breach of forensic orders. This study provides insights into this unique patient group and further clarifies their psychiatric treatment and biopsychosocial needs. A significant variance was found within patient length of stay throughout each stage of the forensic system. Low rates of readmissions and breaches of forensic orders were found. Additional research is needed in this low secure psychiatric rehabilitation setting to clarify the forensic pathways of care and needs amongst this cohort.

Evaluating the Risk of Suicide and Violence in Severe Mental Illness: A Feasibility Study of Two Risk Assessment Tools (OxMIS and OxMIV) in General Psychiatric Settings

BACKGROUND

Two OxRisk risk assessment tools, the Oxford Mental Illness and Suicide (OxMIS) and the Oxford Mental Illness and Violence (OxMIV), were developed and validated using national linked registries in Sweden, to assess suicide and violence risk in individuals with severe mental illness (schizophrenia-spectrum disorders and bipolar disorders). In this study, we aim to examine the feasibility and acceptability of the tools in three different clinical services.

METHOD

We employed a two-step mixed-methods approach, by combining quantitative analyses of risk scores of 147 individual patients, and thematic analyses of qualitative data. First, 38 clinicians were asked to use OxMIS and OxMIV when conducting their routine risk assessments in patients with severe mental illness. The risk scores for each patient (which provide a probability of the outcome over 12 months) were then compared to the unstructured clinical risk assessment made by the treating clinician. Second, we carried out semi-structured interviews with the clinicians on the acceptability and utility of the tools. Thematic analysis was conducted on the qualitative data to identify common themes, in terms of the utility, accuracy, and acceptability of the tools. The investigations were undertaken in three general adult psychiatric clinics located in the cities of Barcelona and Sevilla (Spain), and Changsha (China).

RESULTS

Median risk probabilities over 12 months for OxMIS were 1.0% in the Spanish patient sample and 1.9% in the Chinese sample. For OxMIV, they were 0.7% (Spanish) and 0.8% (Chinese). In the thematic analysis, clinicians described the tools as easy to use, and thought that the risk score improved risk management. Potential additions to predictors were suggested, including family history and the patient's support network. Concordance rates of risk estimates between the tools and clinicians was high for violence (94.4%; 68/72) and moderate for suicide (50.0%; 36/72).

CONCLUSION

Both OxMIS and OxMIV are feasible and practical in different general adult psychiatric settings. Clinicians interviewed found that both tools provide a useful structured approach to estimate the risk of suicide and violence. Risk scores from OxMIS and OxMIV can also be used to assist clinical decision-making for future management.

Availability of opioid agonist treatment and critical incidents in Forensic Clinics for Dependency Diseases in Germany

BACKGROUND

Prevalence of substance use disorders, especially opioid use disorders, is high in patients admitted into forensic psychiatric settings. Opioid agonist treatment is a safe, well-established, and effective treatment option for patients that suffer from opioid dependence. Surprisingly, data on the availability and practice of opioid agonist treatment (OAT) options in German Forensic Clinics for Dependency Diseases is rare. Furthermore, essential data on the prevalence of critical incidents such as violent behavior, relapse, or escape from the clinic are missing for this particular treatment setting.

MATERIALS AND METHODS

We conducted an observational study on all forensic addiction treatment units in Germany (Sect. 64 of the German Criminal Code). A questionnaire on the availability and practice of OAT was sent to all Forensic Clinics for Dependency Diseases in Germany. Following items were assessed: availability and the total number of patients that received an OAT in 2018, available medication options, specific reasons for start and end of OAT, number of treatments terminated without success, number of successful treatments, and critical incidents such as violent behavior, relapse, escape and reoffending. We compared the forensic clinics that offered OAT with those that did not offer this treatment option. The data were analyzed descriptively. Mean and standard deviation was calculated for metric scaled variables. For categorical variables, absolute and relative frequencies were calculated. The two groups (OAT vs. Non-OAT institutions) were compared concerning the given variables by either using Fishers exact test (categorical variables), t-test (normally distributed metric variables), or Wilcoxon-test (metric variables not normally distributed).

RESULTS

In total, 15 of 46 Forensic Clinics for Dependency Diseases participated in the study (33%). In total, 2,483 patients were treated in the participating clinics, 18% were relocated into prison due to treatment termination, and 15% were discharged successfully in 2018. 275 critical incidents were reported: violence against a patient (4%), violence against staff (1.6%), escape (4.7%) and reoffending in (0.5%). In seven clinics treating 1,153 patients, an OAT was available. OAT options in forensic clinics were buprenorphine/naloxone, buprenorphine, methadone, and levomethadone. Regarding critical incidents and successful discharge, no differences were detected in the clinics with or without an OAT. In the clinics that offered an OAT, we found a significantly higher rate of treatment termination without success (p < 0.007) in comparison to clinics without an OAT program. Ninety-nine patients received an OAT, and this treatment was ended due to illegal drug abuse (57%), refusal to give a urine drug sample (71%), and cases where the OAT was given away to other patients (85%).

CONCLUSION

In Forensic Clinics for Dependency Diseases in Germany, OAT is not available in every institution, and thus, access is limited. Critical incidents such as violent behavior against staff or patients and escape are not uncommon in these forensic treatment settings. Further studies are needed to enhance the understanding of OAT practice and the risks for patients and staff.

Schizophrenia and substance use disorder: Characteristics of coexisting issues in a forensic setting

BACKGROUND AND AIMS

Recent research has identified higher prevalence of offending behavior in patients with comorbid schizophrenia spectrum disorder (SSD) and substance use disorder (SUD) compared to patients with SSD only and to the general population. However, findings on the subgroup of patients with SUD, SSD and offending behavior in forensic psychiatric care are scarce and inconsistent. The present study used machine learning to uncover more detailed characteristics of offender patients in forensic psychiatric care with comorbid SSD and SUD.

METHODS

Using machine learning algorithms, 370 offender patients (91.6 % male, mean age of M = 34.1, SD = 10.2) and 558 variables were explored in order to build three models to differentiate between no substance use disorder, cannabis use disorder and any other substance use disorder. To counteract the risk of overfitting, the dataset was split, employing variable filtering, machine learning model building and selection embedded in a nested resampling approach on one subset. The best model was then selected and validated on the second data subset.

RESULTS

Distinguishing between SUD vs. no drug use disorder yielded models with an AUC of 70 and 78. Variables assignable to demographics, social disintegration, antisocial behavior and illness were identified as most influential for the distinction. The model comparing cannabis use disorder with other substance use disorders provided no significant differences.

CONCLUSIONS

From a clinical perspective, offender patients suffering from schizophrenia spectrum and comorbid substance use disorder seem particularly challenging to treat, but initial differences in psychopathology will dissipate over inpatient treatment. Our data suggest that offender patients may benefit from appropriate treatment that focuses on illicit drug abuse to reduce criminal behavior and improve social integration.

Transcranial Direct Current Stimulation Targeting the Ventromedial Prefrontal Cortex Reduces Reactive Aggression and Modulates Electrophysiological Responses in a Forensic Population

BACKGROUND

Studies have shown that impairments in the ventromedial prefrontal cortex play a crucial role in violent behavior in forensic patients who also abuse cocaine and alcohol. Moreover, interventions that aimed to reduce violence risk in those patients are found not to be optimal. A promising intervention might be to modulate the ventromedial prefrontal cortex by high-definition (HD) transcranial direct current stimulation (tDCS). The current study aimed to examine HD-tDCS as an intervention to increase empathic abilities and reduce violent behavior in forensic substance dependent offenders. In addition, using electroencephalography, we examined the effects on the P3 and the late positive potential of the event-related potentials in reaction to situations that depict victims of aggression.

METHODS

Fifty male forensic patients with a substance dependence were tested in a double-blind, placebo-controlled randomized study. The patients received HD-tDCS 2 times a day for 20 minutes for 5 consecutive days. Before and after the intervention, the patients completed self-reports and performed the Point Subtraction Aggression Paradigm, and electroencephalography was recorded while patients performed an empathy task.

RESULTS

Results showed a decrease in aggressive responses on the Point Subtraction Aggression Paradigm and in self-reported reactive aggression in the active tDCS group. Additionally, we found a general increase in late positive potential amplitude after active tDCS. No effects on trait empathy and the P3 were found.

CONCLUSIONS

Current findings are the first to find positive effects of HD-tDCS in reducing aggression and modulating electrophysiological responses in forensic patients, showing the potential of using tDCS as an intervention to reduce aggression in forensic mental health care.

A Bad Start: The Combined Effects of Early Onset Substance Use and ADHD and CD on Criminality Patterns, Substance Abuse and Psychiatric Comorbidity among Young Violent Offenders

Substance abuse, conduct disorder (CD) and attention deficit/hyperactivity disorder (ADHD) are all known risk factors for developing aggressive behaviors, criminality, other psychiatric comorbidity and substance use disorders (SUD). Since early age of onset is important for aggravating the impact of several of these risk factors, the aim of the present study was to investigate whether young adult violent offenders with different patterns of early onset externalizing problems (here: substance use < age 15, ADHD, CD) had resulted in different criminality profiles, substance use problem profiles and psychiatric comorbidity in young adult age. A mixed-method approach was used, combining a variable-oriented approach (with Kruskal Wallis tests) and a person-oriented approach (with Configural frequency analysis). Overall, this combined approach indicated that persons with combined ADHD+CD and persons with CD + early onset of substance use had a more varied history of violent crimes, a more comprehensive history of aggressive behaviors in general, and more psychiatric comorbidity, as well as more varied SUD and destructive substance abuse in adult age, than persons without ADHD, CD or early SU. Results are in line with previous variable-oriented research, but also indicate that individuals in this group with heavy problem aggregation early in life have a wider spectrum of problems in young adult age. Importantly, among these young violent offenders, problem aggregation was the overwhelming norm, and not the exception, as in studies of the general population. This emphasizes the need for early coordinated interventions, but also that treatment within correctional facilities in adult age needs to be comprehensive and take individual patterns of comorbidity into account.

Uncovering social-contextual and individual mental health factors associated with violence via computational inference

The identification of human violence determinants has sparked multiple questions from different academic fields. Innovative methodological assessments of the weight and interaction of multiple determinants are still required. Here, we examine multiple features potentially associated with confessed acts of violence in ex-members of illegal armed groups in Colombia (N = 26,349) through deep learning and feature-derived machine learning. We assessed 162 social-contextual and individual mental health potential predictors of historical data regarding consequentialist, appetitive, retaliative, and reactive domains of violence. Deep learning yields high accuracy using the full set of determinants. Progressive feature elimination revealed that contextual factors were more important than individual factors. Combined social network adversities, membership identification, and normalization of violence were among the more accurate social-contextual factors. To a lesser extent the best individual factors were personality traits (borderline, paranoid, and antisocial) and psychiatric symptoms. The results provide a population-based computational classification regarding historical assessments of violence in vulnerable populations.

Aggression Amongst Outpatients With Schizophrenia and Related Psychoses in a Tertiary Mental Health Institution

Aims: Aggression is defined as "any behavior intended to cause physical, emotional, or psychological harm to another." The aims of the current study were to (i) examine underlying factor structure of the Buss-Perry Aggression Questionnaire (BPAQ) and (ii) explore socio-demographic and clinical correlates (symptom severity, substance use and alcohol use) among patients with schizophrenia and related psychoses in a multi-ethnic Asian population. Methods: Data collected from 397 participants who were seeking outpatient treatment for schizophrenia and related psychoses at a tertiary psychiatric hospital were included in the analyses. BPAQ, a 29-item, four-factor instrument that measures physical aggression, verbal aggression, anger and hostility was used to assess aggression. Data on socio-demographic variables, age of onset of illness, drug use, alcohol use and symptom severity were also collected. Confirmatory factor analysis (CFA) was performed to establish the underlying factor structure of the BPAQ. Multiple regression analyses were utilized to examine socio-demographic and clinical correlates of the BPAQ factors. Results: The mean age of the participants was 36.2 years (SD = 10.9, range: 21-65). Factor structure obtained from the CFA indicated that a higher order four-factor solution had an acceptable fit to the observed data (WLSMV χ² = 1,025.35, df = 320, RMSEA = 0.07, CFI = 0.94, TLI = 0.93, SRMR = 0.05). Females had lower physical aggression and hostility scores as compared to males. Those with lower education had higher physical aggression scores as compared to those with higher education. Participants who received a diagnosis after the age of 30 years had higher physical aggression and anger scores as compared to those who received a diagnosis at or before 20 years of age. Symptom severity was positively associated with higher BPAQ scores. Conclusion: The study findings demonstrated high internal consistency and applicable measurement factor structure of BPAQ in this study sample, making it an appropriate questionnaire for assessing aggressive behavior in this population. We also identified socio-demographic and clinical factors that were associated with aggression in patients with schizophrenia and related psychoses.

Beyond the Mind-Serum Trace Element Levels in Schizophrenic Patients: A Systematic Review

The alterations in serum trace element levels are common phenomena observed in patients with different psychiatric conditions such as schizophrenia, autism spectrum disorder, or major depressive disorder. The fluctuations in the trace element concentrations might act as potential diagnostic and prognostic biomarkers of many psychiatric and neurological disorders. This paper aimed to assess the alterations in serum trace element concentrations in patients with a diagnosed schizophrenia. The authors made a systematic review, extracting papers from the PubMed, Web of Science, and Scopus databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Among 5009 articles identified through database searching, 59 of them were assessed for eligibility. Ultimately, 33 articles were included in the qualitative synthesis. This review includes the analysis of serum levels of the following trace elements: iron, nickel, molybdenum, phosphorus, lead, chromium, antimony, uranium, magnesium, aluminum, zinc, copper, selenium, calcium, and manganese. Currently, there is no consistency regarding serum trace element levels in schizophrenic patients. Thus, it cannot be considered as a reliable prognostic or diagnostic marker of schizophrenia. However, it can be assumed that altered concentrations of those elements are crucial regarding the onset and exaggeration of either psychotic or negative symptoms or cognitive dysfunctions.

Demographic, clinical and forensic characteristics of alleged offenders referred to West End Specialised Hospital, Kimberley, South Africa

The study investigated demographic, clinical and forensic characteristics of alleged offenders referred for forensic assessment. A data collection form was used to gather information from 155 offenders' clinical records. The subjects were mainly young males, aged between 18 and 35 years, with low educational levels and high unemployment rate. The most common diagnoses were substance-related and addictive disorders, and schizophrenia spectrum and other psychotic disorders. A sizeable number of offenders were diagnosed with an intellectual disability. The comorbidity of other medical conditions such as epilepsy and HIV/AIDS was also noteworthy. In total, 55.5% of the offenders were found competent to stand trial, and 46.5% were declared criminally responsible. Offenders presenting with schizophrenia and intellectual disabilities were often declared incompetent to stand trial and were generally not responsible for alleged crimes. There was association between adjudicative competence and criminal responsibility. The results highlight effect of substances on mental illness and crime.

Impact of substance use and other risk factor exposures on conviction rates by people with a psychotic illness and other mental disorders

PURPOSE

To examine the impact of substance use and other risk factors on conviction rates in people with a psychotic illness (PI) and other mental disorders (OMD) compared to those with no mental illness (NMI).

METHODS

This research is part of a longitudinal record-linked whole-population study of 467,945 children born in Western Australia (WA) between 1980 and 2001. This cohort was identified through linkages between the WA psychiatric case register, WA corrective services data and other state-wide registers. We assessed 184,147 individuals born during 1983-1991 to explore the impact of exposure to a variety of risk factors on conviction rates.

RESULTS

People with PI and OMD had higher conviction rates than those with NMI, with unadjusted incidence rate ratios (IRR) of 3.98 (95% CI 3.67-4.32) for PI and 3.18 (95% CI 3.03-3.34) for OMD. Adjusting for substance use reduced the rates by 60% in PI and 30% in OMD: IRRs 1.59 (95% CI 1.45-1.74) and 2.24 (2.12-2.37), respectively. Minimal change was seen when adjusting for other potential risk factors (including socio-demographics, victimisation and parental offending), with adjusted IRRs 1.58 (95% CI 1.43-1.74) for PI and 1.90 (95% CI 1.80-2.02) for OMD.

CONCLUSIONS

Our analysis shows people with a mental illness have higher rates of conviction than those with NMI. Substance use has a major impact on this rate. Results suggest the need for a greater investment in programs addressing the issue of comorbid substance use with a view to reduce the rate of convictions in this population.

Strong Associations Between Childhood Victimization and Community Violence in Male Forensic Mental Health Patients

Background: Childhood abuse and neglect increase the risk of both mental disorders and violent behavior. Associations between child relational adversities and violent behavior have not been extensively investigated in forensic mental health settings. We asked whether the extent of child adversities predicts the extent of violence in the community in forensic mental health patients. Methods: We included 52 male patients at a medium security forensic mental health ward, with diagnoses of predominantly paranoid schizophrenia and other schizophrenia and psychotic disorders. Seventy-five percent had comorbid substance abuse. We extracted information on six types of child adversities based on clinicians' administrations of the Historical Clinical Risk Management 20 version 3 (HCR 20) scale and summary notes in electronic patient journals. These same sources were used to extract information on war trauma and interpersonal violence in the community. We established cumulative scales for exposure to number of types of child adversities and number of incidents of community violence. Results: Physical and emotional abuse, emotional and physical neglect, and bullying were associated with higher levels of community violence. We observed a linear, significant increase in the frequency of community violence with cumulative numbers of child adversity types. Conclusions: Cumulative exposure to child adversities may be associated with higher degrees of violence in forensic mental health patients, with the most violent patients having the most extensive exposures to adversities. An enhanced focus on child adversities in risk assessment and management of violence may be considered in forensic inpatient settings.

Demographic and clinical profiles of admitted psychiatric patients of the East London Mental Health Unit in the Eastern Cape, South Africa

Integration of psychiatric care at the Primary Health Care (PHC) could be an important strategy towards addressing the shortages of in-patient mental health care services in South Africa. This study describes the profiles of admitted psychiatric patients at the East London Mental Health Unit (ELMHU) of the Eastern Cape from January 2016 to December 2016.In this retrospective cross-sectional study, an audit of medical records of all psychiatric in-patients managed at the ELMHU during the study period was undertaken. Simple descriptive and inferential statistics were used to describe the profiles and examine the associations with the common psychiatric conditions.Of the participants with complete data (n = 186), the majority were males (n = 108); single (72.6%) and had secondary education (45.7%). The majority of in-patients were psychotic (38%), violent (31%), manic (16%) or suicidal (9.2%) at the time of admission. Patients who were 35 years and above, resided in urban areas, and presented with suicidal and depressive symptoms were more likely to be admitted voluntarily. Schizophrenia (31.6%), cannabis-related psychiatric disorders (31.6%), bipolar Type-1 disorder (21.9%) and alcohol related disorders (15.5%) were the main reasons for admission. There was a significant association between demographic characteristics and the common psychiatric disorders of the patients.Schizophrenia, bipolar 1 disorder, cannabis-related disorders and alcohol-related disorders are the predominant disorders leading to in- patient mental health care services being utilized in the study setting. Findings might inform training of health care workers at the PHCs with a view to integrating mental health care services in the Eastern Cape.

Psychiatric Hospitalizations of Chronic Psychotic Disorder Patients With and Without Dual Diagnosis, Israel, 1963-2016

Objective: A significant proportion of patients with severe mental illness also experience substance use disorder. For these dual diagnosis (DD) patients, treatment is more complicated and prognosis is worse. Despite the introduction of the Community Rehabilitation of Persons With Mental Health Disability Law in 2000 and ongoing national mental health reforms, psychiatric services in Israel are not meeting the needs of an increasing number of DD patients. This study examines, for the first time in Israel, the prevalence of DD and patterns of psychiatric hospitalizations of chronic psychotic disorder patients with and without substance use disorder. Methods: The National Psychiatric Case Registry provided data on 18,684 persons with schizophrenia/schizoaffective disorders, aged 18-65, with a psychiatric hospitalization during the period 1963-2016 (with at least one hospitalization in 2010-15). Patients were considered as having DD if their substance use disorder was indicated in at least two, or 20%, of hospitalizations. Regression modeling predicted hospitalization measures (number of hospitalizations, total days hospitalized, length of stay). Results were also analyzed by legal status of admission (voluntary or involuntary; psychiatrist-ordered and court-ordered). Results: One-third of patients with chronic psychotic disorder met DD criteria, with a threefold higher rate among males (37.1%) than females (12.8%). Particularly high rates of DD (nearly 50%) were noted among male immigrants from Ethiopia. Compared with non-substance use disorder patients, DD patients had a significantly younger mean age at first hospitalization and shorter average length of stay per hospitalization but a greater number of hospitalizations and total hospital days (p < .0001 for all comparisons). The associations between DD status and hospitalization characteristics remained significant even after accounting for the effects of confounding factors. Hospitalization characteristics were also associated significantly with sex, population group, age, age at first hospitalization, and country of origin. The rate of court-ordered observation or hospitalization was threefold higher in the DD group. Conclusions: These findings, which broadly align with other countries, reflect a scarcity of outpatient services for DD patients with schizophrenia/schizoaffective disorder and substance use disorder. To achieve long-term mental health improvements, an expansion of community-based integrative treatment and rehabilitation services is needed in Israel.

Trajectories of Dynamic Risk Factors as Predictors of Violence and Criminality in Patients Discharged From Mental Health Services: A Longitudinal Study Using Growth Mixture Modeling

Background: Individuals with severe mental illnesses are at greater risk of offenses and violence, though the relationship remains unclear due to the interplay of static and dynamic risk factors. Static factors have generally been emphasized, leaving little room for temporal changes in risk. Hence, this longitudinal study aims to identify subgroups of psychiatric populations at risk of violence and criminality by taking into account the dynamic changes of symptomatology and substance use. Method: A total of 825 patients from the MacArthur Violence Risk Assessment Study having completed five postdischarge follow-ups were analyzed. Individuals were classified into outcome trajectories (violence and criminality). Trajectories were computed for each substance (cannabis, alcohol, and cocaine, alone or combined) and for symptomatology and inputted as dynamic factors, along with other demographic and psychiatric static factors, into binary logistic regressions for predicting violence and criminality. Best predictors were then identified using backward elimination, and receiver operator characteristic (ROC) curves were calculated for both models. Results: Two trajectories were found for violence (low versus high violence). Best predictors for belonging in the high-violence group were low verbal intelligence (baseline), higher psychopathy (baseline) and anger (mean) scores, persistent cannabis use (alone), and persistent moderate affective symptoms. The model's area under the curve (AUC) was 0.773. Two trajectories were also chosen as being optimal for criminality. The final model to predict high criminality yielded an AUC of 0.788, retaining as predictors male sex, lower educational level, higher score of psychopathy (baseline), persistent polysubstance use (cannabis, cocaine, and alcohol), and persistent cannabis use (alone). Both models were moderately predictive of outcomes. Conclusion: Static factors identified as predictors are consistent with previously published literature. Concerning dynamic factors, unexpectedly, cannabis alone was an independent co-occurring variable, as well as affective symptoms, in the violence model. For criminality, our results are novel, as there are very few studies on criminal behaviors in nonforensic psychiatric populations. In conclusion, these results emphasize the need to further study the predictors of crime, separately from violence and the impact of longitudinal patterns of specific substance use and high affective symptoms.

Criminal offending and associated factors in dual diagnosis patients

Dual diagnosis patients perpetrate crime more often than healthy individuals. Crime perpetration has major mental health consequences for the victim. Knowledge of factors related to perpetration is needed for the development of prevention programs. However, in dual diagnosis patients, very little is known about factors explaining criminal behavior. The current study investigated cross-sectional associations between demographic and clinical factors and perpetration of three crime types (violence, threat, and property crime) in 243 treatment-seeking dual diagnosis patients. In our sample, perpetration of violence was independently associated with younger age, severity of alcohol use problems, lifetime trauma exposure, and higher manic symptom scores. Expression of threat was independently associated with severity of alcohol use problems and higher manic symptom scores. Perpetration of property crime was independently associated with severity of alcohol and drug use problems. Remarkably, gender was not associated with any type of perpetration. These findings indicate that criminal offending is a significant problem among dual diagnosis patients and are a first step towards understanding the complex causal networks that lead to criminal perpetration. Future longitudinal research should investigate additional risk factors and establish causality to support the development of treatment programs to prevent criminal offending by dual diagnosis patients.

On the Neurobiological Role of Oxidative Stress in Alcohol-Induced Impulsive, Aggressive and Suicidal Behavior

Objectives: Alcohol abuse is known to result in behavioral impairments (such as increased impulsivity, aggressive, and suicidal behavior), but the neurobiological basis for these behavioral impairments remains unknown. The objective of this review is to propose a neurobiological basis for alcohol-induced aggression, impulsivity, and suicidal behavior. Methods: Search was done by accessing PubMed/Medline, EBSCO, and PsycINFO databases. The search string used was "(Alcohol OR Alcoholism* OR Alcohol Abuse) AND (Behavior* OR Behavioral Impairment or Disorder) AND (Oxidative Stress OR Reactive Oxygen Species)." The electronic databases were searched for titles or abstracts containing these terms in all published articles between January 1, 1960, and May 31, 2019. The search was limited to studies published in English and other languages involving both animal and human subjects. Articles selected included randomized clinical trials (RCTs), observational studies, meta-analyses, and both systemic and narrative reviews, providing both quantitative and qualitative information with a measure of alcohol abuse or alcoholism as an outcome. Exclusion criteria were unpublished data of any form, including conference proceedings and dissertation. New key terms were identified (new term included: "Antioxidants, Neurotransmitters, Dopamine, Serotonin, GABA, Glutamate. Aggression, Impulsivity, Suicidal Behavior, hippocampus, prefrontal cortex, limbic system, psychiatric disorders, PTSD, Anxiety, Depression. These new terms were searched with Alcohol or Alcoholism or Alcohol Abuse and Oxidative Stress separately resulting in the identification of over 3000 articles. 196 were included in this article. Results: Multiple lines of evidence indicate that oxidative stress (OS) plays a critical underlying role in alcohol toxicity and behavioral impairments. Conclusions/Importance: People diagnosed with PTSD, anxiety disorder, depression, and those with a personality high in psychoticism as measured by the P Scale of the Eysenck Personality Questionnaire, with comorbid alcohol abuse or alcohol use disorder (AUD), may display increased impulsivity, aggression, and suicidal behavior because of the potentiating effect of alcohol-induced OS on their elevated brain oxidative status. Antioxidant therapy should be an integral part of acute alcohol intoxication and AUD treatment. Further research is necessary to fully understand the relationship between OS and alcohol-induced behavioral impairments.

Factors associated with referrals to high security forensic services among people with severe mental illness and receiving inpatient care in prison

BACKGROUND

Prison mental health care is a significant topic which has been already studied and described in literature, particularly because of important implications both in the prison and in the health care system. It's not uncommon that inmates suffering from mental disorders are referred to high security forensic services (HSFS) but, to date, studies assessing factors associated with relevant referrals to these services are missing. So, the aim of our study is to investigate socio-demographic, criminological, psychopathological and toxicological variables among those who were referred to HSFS as compared to their non-referred counterpart.

METHODS

We conducted a cross-sectional study recruiting 159 subjects receiving prison inpatient care in an Italian jail, between January 2010 and August 2015. No subjects were excluded from the study. The mean age was 39.

RESULTS

About half of included prisoners suffered from personality disorder while one-third from psychotic disorders. >60% of the subjects had comorbid substance use disorders. The odds of being referred to HSFS were related to previous admission (odds ratio [OR] = 5.34, 95% confidence interval [CI] 1.66-17.16), diagnosis of psychosis (OR = 2.79, 95% CI 1.11-7.04) and cannabis use disorder (OR = 2.68, 95% CI 1.14-6.28). Personality disorder was inversely associated to the referral to forensic facilities (OR = 0.37, 95% CI 0.14-0.97).

CONCLUSIONS

Mental health services should improve preventive measures for vulnerable prisoners in order to reduce criminal recidivism and forensic readmission.

Total hip arthroplasty following illicit drug abuse

BACKGROUND

The role of illicit drug abuse in total joint arthroplasty is largely unknown and is likely underestimated. Patients with drug addictions often suffer from septic osteoarthritis or a necrosis of the femoral head. Purpose of the study was to evaluate the operative management and clinical outcome of total hip replacement in patients with a history of intravenous drug abuse.

METHODS

This retrospective study included 15 patients with a history of intravenous drug abuse who underwent total hip arthroplasty. A total of 6 females and 9 males with an average age of 34.3 years were identified. Ten patients presented an acute bacterial coxitis (Coxitis-group) and five an aseptic osteonecrosis of the femoral head (Osteonecrosis-group).

RESULTS

Ten patients with a bacterial coxitis underwent a two-staged total hip arthroplasty (THA), with temporary insertion of a drug-eluting spacer. Five patients with a necrosis of the femoral head were primarily treated with THA. All patients developed multiple re-infections after insertion of a drug-eluting spacer or THA. Only two patients finally achieved a THA without infection in the period of 3.9 years follow-up. The other 13 patients underwent a Girdlestone arthroplasty (7 patients) or total joint replacement with a chronic fistula (6 patients).

CONCLUSION

THA in patients with illicit drug abuse shows a low success rate. Following septic osteoarthritis or osteonecrosis in drug-addicted patients, we recommend a two-stage procedure with temporary insertion of a drug-eluting spacer. THA might follow only under strict premises.

Predicting time to recall in patients conditionally released from a secure forensic hospital: A survival analysis

BACKGROUND

The recall of conditionally discharged forensic patients in England is a formal order from the Ministry of Justice under the Mental Health Act (1983) which has the power to revoke conditional release and direct readmission to hospital. Recall has significant implications for the individual and for hospital services, but despite this, little is known about predictors of recall for forensic patients.

METHODS

We examined the rate of recall for 101 patients conditionally discharged from medium secure forensic inpatient services between 2007 and 2013. Demographic, clinical, and forensic factors were examined as possible predictors of time to recall using Cox regression survival techniques.

RESULTS

Conditionally discharged patients were followed for an average of 811 days, during which 45 (44.5%) were recalled to hospital. Younger age (HR 1.89; 95% CI 1.02-3.49; p = 0.04), non-white ethnicity (HR 3.44; 95% CI 1.45-8.13), substance abuse history (HR 2.52; 95% CI 1.17-5.43), early violence (HR 1.90; 95% CI 1.03-3.50), early childhood maladjustment (HR 1.92; 95% CI 1.01-3.68), treatment with a depot medication (HR 2.17; 95% CI 1.14-4.11), being known to mental health services (HR 3.44; 95% CI 1.06-11.16), and a psychiatric admission prior to the index admission (HR 2.44; 95% CI 1.08-5.52) were significantly associated with a shorter time to recall. Treatment with clozapine reduced the risk of recall to hospital (HR 0.40; 95% CI 0.20-0.79).

CONCLUSIONS

Time to recall can be predicted by a range of factors that are readily available to clinical teams. Further research is required to determine if targeted interventions can modify the likelihood or time to recall for conditionally released forensic patients.

Method of homicide and severe mental illness: A systematic review

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

East London Modified-Broset as Decision-Making Tool to Predict Seclusion in Psychiatric Intensive Care Units

Seclusion is a last resort intervention for management of aggressive behavior in psychiatric settings. There is no current objective and practical decision-making instrument for seclusion use on psychiatric wards. Our aim was to test the predictive and discriminatory characteristics of the East London Modified-Broset (ELMB), to delineate its decision-making profile for seclusion of adult psychiatric patients, and second to benchmark it against the psychometric properties of the Broset Violence Checklist (BVC). ELMB, an 8-item modified version of the 6-item BVC, was retrospectively employed to evaluate the seclusion decision-making process on two Psychiatric Intensive Care Units (patients n = 201; incidents n = 2,187). Data analyses were carried out using multivariate regression and Receiver Operating Characteristic (ROC) curves. Predictors of seclusion were: physical violence toward staff/patients OR = 24.2; non-compliance with PRN (pro re nata) medications OR = 9.8; and damage to hospital property OR = 2.9. ROC analyses indicated that ELMB was significantly more accurate that BVC, with higher sensitivity, specificity, and positive likelihood ratio. Results were similar across gender. The ELMB is a sensitive and specific instrument that can be used to guide the decision-making process when implementing seclusion.

The Therapeutic Approach to a Patient's Criminal Offense in a Forensic Mental Health Nurse-Patient Relationship-The Nurses' Perspectives

PURPOSE

The purpose of this study is to describe the therapeutic approach to a patient's criminal offense in a forensic mental health nurse-patient relationship from the nurse's perspective.

DESIGN AND METHODS

Eight nurses in a Finnish forensic psychiatric hospital were interviewed, and the resultant research material was analyzed by inductive content analysis.

FINDINGS

The results revealed the process of the therapeutic approach to a patient's offense, which comprises numerous steps and various phases.

PRACTICE IMPLICATIONS

For the nurse, the process of working through the offense can be divided into stages in which an attempt is made to respond to the patient's behavior and interaction in a manner that leads to working through the criminal act.

Association Between Deliberate Self-harm and Violent Criminality

IMPORTANCE

Individuals who self-harm may have an increased risk of aggression toward others, but this association has been insufficiently investigated. More conclusive evidence may affect assessment, treatment interventions, and clinical guidelines.

OBJECTIVE

To investigate the association between nonfatal self-harm and violent crime.

DESIGN, SETTING, AND PARTICIPANTS

This population-based longitudinal cohort study, conducted from January 1, 1997, through December 31, 2013, studied all Swedish citizens born between 1982 and 1998 who were 15 years and older (N = 1 850 252). Individuals who emigrated from Sweden before the age of 15 years (n = 104 051) or immigrated to Sweden after the age of 13 years (ie, <2 years before the beginning of the follow-up; n = 22 009) were excluded. Data analysis was performed from April 21, 2016, to June 4, 2016.

EXPOSURES

Receipt of self-harm-associated clinical care.

MAIN OUTCOMES AND MEASURES

Conviction of a violent crime according to the Swedish penal code.

RESULTS

The study cohort consisted of 1 850 525 individuals (950 382 males and 900 143 females), and the mean (SD) follow-up time was 8.1 (4.7) years (range, 0-17.0 years; minimum age, 15 years; maximum age, 32 years). During a mean follow-up period of 8.1 years, 55 185 individuals (3.0%) received clinical care for self-harm. The crude hazard ratio was 4.9 (95% CI, 4.8-5.0) for violent crime conviction in exposed individuals compared with the unexposed group. Women who self-harm were at particularly high risk for expressing violent behaviors. After adjustment for relevant psychiatric comorbidities and socioeconomic status, an almost doubled hazard of violent offense remained (hazard ratio, 1.8; 95% CI, 1.8-1.9).

CONCLUSIONS AND RELEVANCE

Self-harm is associated with an increased risk of conviction for a violent offense in both sexes. The risk of violence, as well as the risk of suicide and self-harm, should be assessed among offending and self-harming individuals.

Homicide and mental disorder in a region with a high homicide rate

There are few studies of the relationship between mental disorder and homicide offences from regions with high rates of homicide. We examined the characteristics and psychiatric diagnoses of homicide offenders from the Chuvash Republic of the Russian Federation, a region of Russia with a high total homicide rate. In the 30 years between 1981 and 2010, 3414 homicide offenders were the subjected to pre-trial evaluations by experienced psychiatrists, almost half of whom (1596, 46.7%) met the international classification of diseases (ICD) 10 criteria for at least one mental disorder. The six most common individual diagnoses were alcohol dependence (15.9%), acquired organic mental disorder (7.3%), personality disorder (7.1%), schizophrenia (4.4%) and intellectual disability (3.6%). More than one disorder was found in 7.4% of offenders and alcohol dependence was the most frequently diagnosed co-morbid disorder. One in ten offenders were found to be not criminally responsible for their actions. Few homicides involved the use of substances other than alcohol, and firearms were used in 1.6% of homicides. The finding that people with mental disorders other than psychosis committed a high proportion of homicides in a region with a high rate of homicide, suggests that people with mental disorders are vulnerable to similar sociological factors to those that contribute to homicide offences by people who do not have mental disorder.

Validating the Hamilton Anatomy of Risk Management–Forensic Version and the Aggressive Incidents Scale

The Hamilton Anatomy of Risk Management–Forensic Version (HARM-FV) is a structured professional judgement tool of violence risk developed for use in forensic inpatient psychiatric settings. The HARM-FV is used with the Aggressive Incidents Scale (AIS), which provides a standardized method of recording aggressive incidents. We report the findings of the concurrent validity of the HARM-FV and the AIS with widely used measures of violence risk and aggressive acts, the Historical, Clinical, Risk Management–20, Version 3 (HCR-20V3) and a modified version of the Overt Aggression Scale. We also present findings on the predictive validity of the HARM-FV in the short term (1-month follow-up periods) for varying severities of aggressive acts. The results indicated strong support for the concurrent validity of the HARM-FV and AIS and promising support for the predictive accuracy of the tool for inpatient aggression. This article provides support for the continued clinical use of the HARM-FV within an inpatient forensic setting and highlights areas for further research.

Prediction of violent reoffending on release from prison: derivation and external validation of a scalable tool

BACKGROUND

More than 30 million people are released from prison worldwide every year, who include a group at high risk of perpetrating interpersonal violence. Because there is considerable inconsistency and inefficiency in identifying those who would benefit from interventions to reduce this risk, we developed and validated a clinical prediction rule to determine the risk of violent offending in released prisoners.

METHODS

We did a cohort study of a population of released prisoners in Sweden. Through linkage of population-based registers, we developed predictive models for violent reoffending for the cohort. First, we developed a derivation model to determine the strength of prespecified, routinely obtained criminal history, sociodemographic, and clinical risk factors using multivariable Cox proportional hazard regression, and then tested them in an external validation. We measured discrimination and calibration for prediction of our primary outcome of violent reoffending at 1 and 2 years using cutoffs of 10% for 1-year risk and 20% for 2-year risk.

FINDINGS

We identified a cohort of 47 326 prisoners released in Sweden between 2001 and 2009, with 11 263 incidents of violent reoffending during this period. We developed a 14-item derivation model to predict violent reoffending and tested it in an external validation (assigning 37 100 individuals to the derivation sample and 10 226 to the validation sample). The model showed good measures of discrimination (Harrell's c-index 0·74) and calibration. For risk of violent reoffending at 1 year, sensitivity was 76% (95% CI 73-79) and specificity was 61% (95% CI 60-62). Positive and negative predictive values were 21% (95% CI 19-22) and 95% (95% CI 94-96), respectively. At 2 years, sensitivity was 67% (95% CI 64-69) and specificity was 70% (95% CI 69-72). Positive and negative predictive values were 37% (95% CI 35-39) and 89% (95% CI 88-90), respectively. Of individuals with a predicted risk of violent reoffending of 50% or more, 88% had drug and alcohol use disorders. We used the model to generate a simple, web-based, risk calculator (OxRec) that is free to use.

INTERPRETATION

We have developed a prediction model in a Swedish prison population that can assist with decision making on release by identifying those who are at low risk of future violent offending, and those at high risk of violent reoffending who might benefit from drug and alcohol treatment. Further assessments in other populations and countries are needed.

FUNDING

Wellcome Trust, the Swedish Research Council, and the Swedish Research Council for Health, Working Life and Welfare.

Sexual offending runs in families: A 37-year nationwide study

BACKGROUND

Sexual crime is an important public health concern. The possible causes of sexual aggression, however, remain uncertain.

METHODS

We examined familial aggregation and the contribution of genetic and environmental factors to sexual crime by linking longitudinal, nationwide Swedish crime and multigenerational family registers. We included all men convicted of any sexual offence (N = 21,566), specifically rape of an adult (N = 6131) and child molestation (N = 4465), from 1973 to 2009. Sexual crime rates among fathers and brothers of sexual offenders were compared with corresponding rates in fathers and brothers of age-matched population control men without sexual crime convictions. We also modelled the relative influence of genetic and environmental factors to the liability of sexual offending.

RESULTS

We found strong familial aggregation of sexual crime [odds ratio (OR) = 5.1, 95% confidence interval (CI) = 4.5-5.9] among full brothers of convicted sexual offenders. Familial aggregation was lower in father-son dyads (OR = 3.7, 95% CI = 3.2-4.4) among paternal half-brothers (OR = 2.1, 95% CI = 1.5-2.9) and maternal half-brothers (OR = 1.7, 95% CI = 1.2-2.4). Statistical modelling of the strength and patterns of familial aggregation suggested that genetic factors (40%) and non-shared environmental factors (58%) explained the liability to offend sexually more than shared environmental influences (2%). Further, genetic effects tended to be weaker for rape of an adult (19%) than for child molestation (46%).

CONCLUSIONS

We report strong evidence of familial clustering of sexual offending, primarily accounted for by genes rather than shared environmental influences. Future research should possibly test the effectiveness of selective prevention efforts for male first-degree relatives of sexually aggressive individuals, and consider familial risk in sexual violence risk assessment.

Childhood maltreatment and violence: mediation through psychiatric morbidity

Childhood maltreatment is associated with multiple adverse outcomes in adulthood including poor mental health and violence. We investigated direct and indirect pathways from childhood maltreatment to adult violence perpetration and the explanatory role of psychiatric morbidity. Analyses were based on a population survey of 2,928 young men 21-34 years in Great Britain in 2011, with boost surveys of black and minority ethnic groups and lower social grades. Respondents completed questionnaires measuring psychiatric diagnoses using standardized screening instruments, including antisocial personality disorder (ASPD), drug and alcohol dependence and psychosis. Maltreatment exposures included childhood physical abuse, neglect, witnessing domestic violence and being bullied. Adult violence outcomes included: any violence, violence toward strangers and intimate partners (IPV), victim injury and minor violence. Witnessing domestic violence showed the strongest risk for adult violence (AOR 2.70, 95% CI 2.00, 3.65) through a direct pathway, with psychotic symptoms and ASPD as partial mediators. Childhood physical abuse was associated with IPV (AOR 2.33, 95% CI 1.25, 4.35), mediated by ASPD and alcohol dependence. Neglect was associated with violence toward strangers (AOR 1.73, 95% CI 1.03, 2.91), mediated by ASPD. Prevention of violence in adulthood following childhood physical abuse and neglect requires treatment interventions for associated alcohol dependence, psychosis, and ASPD. However, witnessing family violence in childhood had strongest and direct effects on the pathway to adult violence, with important implications for primary prevention. In this context, prevention strategies should prioritize and focus on early childhood exposure to violence in the family home.

Risk Factors for Problematic Behaviors among Forensic Outpatients under the Medical Treatment and Supervision Act in Japan

The Medical Treatment and Supervision Act (MTSA) was enacted in 2005 in Japan to promote the reintegration of clinical offenders with mental disorders into society. Under the MTSA, individuals who committed serious crimes in a state of insanity or diminished responsibility are diverted from the criminal justice system to the mental health system. Based on court decisions about MTSA-based treatment, clinical offenders have an obligation to engage in rehabilitation within their local community under the guidance of mental health professionals. However, patients under MTSA-based clinical treatments have faced various problems in the course of treatment, because of psychiatric as well as other static or dynamic factors, and sometimes have committed problematic behaviors, such as violence and medical non-compliance. Hence, this study aimed to clarify factors related to patients' inclusion in MTSA-based outpatient treatment and additionally, their commitment of problematic behaviors, based on confidential data acquired during a four-year government survey period (National Center of Neurology and Psychiatry) from MTSA enactment (July 15, 2005) to December 31, 2009. In total, we recruited 441 clinical offenders receiving MTSA-based outpatient treatment from 158 nationwide facilities. To evaluate related factors, we collected demographic, psychiatric, forensic, clinical treatment, and social service information. Statistical analyses demonstrated that predominant profiles of patients included male gender, younger age, low school history, psychiatric diagnoses (F1, F2, and F3), and no correctional or outpatient history before MTSA-based treatment. F1 or substance use diagnosis, in particular, was increasingly correlated with other factors, such as male gender, older age, and correctional history before MTSA treatment. Among the 441 patients, 189 (43%) committed problematic behaviors in the course of the MTSA-based outpatient treatment. Risk factors for patients' commitment of problematic behaviors comprised F1 diagnosis and inpatient history before MTSA-based treatment inclusion. In summary, reduction of overall problematic behaviors under the MTSA outpatient likely makes progress by focal attention to patients with psychiatric disorders caused by substance use and/or a past inpatient history for more severe psychiatric symptoms. This work is of ongoing and future importance in the domain of forensic community treatment, to connect risk-enhancing factors with risk management.

Prospective cohort study of the relationship between neuro-cognition, social cognition and violence in forensic patients with schizophrenia and schizoaffective disorder

BACKGROUND

There is a broad literature suggesting that cognitive difficulties are associated with violence across a variety of groups. Although neurocognitive and social cognitive deficits are core features of schizophrenia, evidence of a relationship between cognitive impairments and violence within this patient population has been mixed.

METHODS

We prospectively examined whether neurocognition and social cognition predicted inpatient violence amongst patients with schizophrenia and schizoaffective disorder (n = 89; 10 violent) over a 12 month period. Neurocognition and social cognition were assessed using the MATRICS Consensus Cognitive Battery (MCCB).

RESULTS

Using multivariate analysis neurocognition and social cognition variables could account for 34 % of the variance in violent incidents after controlling for age and gender. Scores on a social cognitive reasoning task (MSCEIT) were significantly lower for the violent compared to nonviolent group and produced the largest effect size. Mediation analysis showed that the relationship between neurocognition and violence was completely mediated by each of the following variables independently: social cognition (MSCEIT), symptoms (PANSS Total Score), social functioning (SOFAS) and violence proneness (HCR-20 Total Score). There was no evidence of a serial pathway between neurocognition and multiple mediators and violence, and only social cognition and violence proneness operated in parallel as significant mediators accounting for 46 % of the variance in violent incidents. There was also no evidence that neurocogniton mediated the relationship between any of these variables and violence.

CONCLUSIONS

Of all the predictors examined, neurocognition was the only variable whose effects on violence consistently showed evidence of mediation. Neurocognition operates as a distal risk factor mediated through more proximal factors. Social cognition in contrast has a direct effect on violence independent of neurocognition, violence proneness and symptom severity. The neurocognitive impairment experienced by patients with schizophrenia spectrum disorders may create the foundation for the emergence of a range of risk factors for violence including deficits in social reasoning, symptoms, social functioning, and HCR-20 risk items, which in turn are causally related to violence.