Substance misuse and violence: the scope and limitations of forensic psychiatry's role

Longitudinal Associations among Depression, substance Abuse, and Crime: A Test of competing Hypotheses for Driving Mechanisms

PURPOSE

Crime, depression, and substance abuse, often co-occur. This study examined competing models considering each problem domain individually as a driving mechanism for the other problems to better understand etiology and inform prevention efforts. Gender differences were also examined.

METHODS

Data were drawn from the Seattle Social Development Project, a multiethnic and gender-balanced urban panel of 808 participants constituted in 1985. Cross- lagged models examined prospective assessments of early (grades 7 & 8) and late (grades 9-12) adolescent internalizing problems, substance use, and delinquency, as well as measures of depression, substance dependence, and crime at early adulthood (ages 21-24) and later adulthood (ages 27-30).

RESULTS

Comparisons of nested models by gender showed (a) continuity in internalizing behaviors/depression, substance use/dependence, and delinquency/crime for both women and men; (b) accounting for continuity, depression did not consistently drive other problems for either women or men; (c) among women, both substance abuse and crime appeared to be important driving mechanisms; and (d) among men, crime emerged as the most pertinent driving mechanism.

CONCLUSION

Findings suggest that externalizing problems may be more important driving mechanisms for depression than vice versa. Preventing crime and substance abuse may have the important added benefit of reducing early adult depression.

De-escalation techniques for managing non-psychosis induced aggression in adults

BACKGROUND

Aggression occurs frequently within health and social care settings. It can result in injury to patients and staff and can adversely affect staff performance and well-being. De-escalation is a widely used and recommended intervention for managing aggression, but the efficacy of the intervention as a whole and the specific techniques that comprise it are unclear.

OBJECTIVES

To assess the effects of de-escalation techniques for managing non-psychosis-induced aggression in adults in care settings, in both staff and service users.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL and 14 other databases in September 2017, plus three trials registers in October 2017. We also checked references, and contacted study authors and authorities in the field to identify additional published and unpublished studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs comparing de-escalation techniques with standard practice or alternative techniques for managing aggressive behaviour in adult care settings. We excluded studies in which participants had psychosis.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

This review includes just one cluster-randomised study of 306 older people with dementia and an average age of 86 years, conducted across 16 nursing homes in France. The study did not measure any of our primary or secondary outcomes but did measure behavioural change using three measurement scales: the Cohen-Mansfield Agitation Inventory (CMAI; 29-item scale), the Neuropsychiatric Inventory (NPI; 12-item scale), and the Observation Scale (OS; 25-item scale). For the CMAI, the study reports a Global score (29 items rated on a seven-point scale (1 = never occurs to 7 = occurs several times an hour) and summed to give a total score ranging from 29 to 203) and mean scores (evaluable items (rated on the same 7-point scale) divided by the theoretical total number of items) for the following four domains: Physically Non-Aggressive Behaviour, such as pacing (13 items); Verbally Non-Aggressive Behaviour, such as repetition (four items); Physically Aggressive Behaviour, such as hitting (nine items); and Verbally Aggressive Behaviour, such as swearing (three items). Four of the five CMAI scales improved in the intervention group (Global: change mean difference (MD) -5.69 points, 95% confidence interval (CI) -9.59 to -1.79; Physically Non-Aggressive: change MD -0.32 points, 95% CI -0.49 to -0.15; Verbally Non-Aggressive: change MD -0.44 points, 95% CI -0.69 to -0.19; and Verbally Aggressive: change MD -0.16 points, 95% CI -0.31 to -0.01). There was no difference in change scores on the Physically Aggressive scale (MD -0.08 points, 95% CI -0.37 to 0.21). Using GRADE guidelines, we rated the quality of this evidence as very low due to high risk of bias and indirectness of the outcome measures. There were no differences in NPI or OS change scores between groups by the end of the study.We also identified one ongoing study.

AUTHORS' CONCLUSIONS

The limited evidence means that uncertainty remains around the effectiveness of de-escalation and the relative efficacy of different techniques. High-quality research on the effectiveness of this intervention is therefore urgently needed.

The use of ‘drug dogs' in psychiatry

Comorbidity of severe mental illness and substance misuse is now common in general psychiatry (Regier et al, 1990), and perhaps almost standard in forensic psychiatry (Snowden, 2001). It is also reflected in child and adolescent psychiatry (Boys et al, 2003) and even in old age psychiatry (Jolley et al, 2004). The range of hazards associated with substance misuse in people with mental illnesses includes elevated risk of relapse of psychosis (Cantwell & Harrison, 1996), increased frequency of hospitalisation (Bartels et al, 1993), poorer compliance with treatment (Jablensky et al, 1992), higher levels of treatment-resistance (Bowers et al, 1990), impairment of the integrity of therapeutic regimes in hospital settings and in hostels in the community (Sandford, 1995), stress in the community (Drake & Wallach, 1989), higher rates of homelessness (Scheller-Gilkey et al, 1999), increased suicidality (Drake & Wallach, 1989), and increased potential for antisocial behaviour and crime of both an acquisitive and a violent nature (Stewart et al, 2000; Sinha & Easton, 1999). The misuse of substances is therefore a significant obstruction to the effective use of psychiatric treatment, and the financial cost associated with such clinical adversity must run into millions of pounds.

An exploratory study investigating the impact of the procedures used to manage patient substance misuse on nurse-patient relationships in a medium secure forensic unit

The role conflict experienced by forensic psychiatric nurses between their therapeutic responsibilities and their responsibility to operationalize security procedures is well established in the literature. There has been less investigation into how this role conflict is played out specifically in the management of inpatient substance misuse in forensic units. This study, therefore, aimed to explore the views of nurses working in one medium secure unit of the impact of the procedures used to manage substance misuse (partial strip searching, room searching, canine searching, 'pat' (or 'rubdown') searching, urine drug screening) on their relationships with patients. Ten interviews of registered mental health nurses working in a medium secure unit in the Northwest were carried out. The interview data were transcribed verbatim and framework analysis used to identify emergent themes. The impact of the procedures on nurse-patient relationships was reported as largely negative by the participants. They reported that the intrusion of the procedures had a detrimental effect on their relationships with patients. The relative degree of intrusion posed by each of the procedures was an important factor in determining the extent and duration of damage to nurse-patient relationships, as was the communication skills of the nurse conducting the procedure.

Drug-associated psychoses and criminal responsibility

At present, the law draws a distinction when assigning criminal responsibility to those who commit offences while experiencing psychotic symptoms: if the symptoms are believed to arise because of ingesting drugs (an external cause), the offender is generally convicted of the offence; if the symptoms arise from a mental illness (an internal cause), the offender may be afforded a defence of insanity. In practice, drawing such a distinction can be problematic. There are difficulties for example in determining criminal responsibility when the use of drugs is followed by the emergence of a psychotic illness process that then continues to have an independent existence even in the absence of the ongoing substance use. This article analyses legal, policy, and expert witness perspectives relating to liberal, conservative, and intermediate approaches to this problematic area of jurisprudence.