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Purpose: Community care replaced institutional care for people with psychosis without guidance about what constituted effective treatment. In a Swedish birth cohort, many of those who developed schizophrenia or bipolar disorder as community care was being implemented were subsequently convicted of violent and non-violent crimes. Studies from other countries that were implementing community care at this time also reported elevated proportions of patients acquiring criminal convictions. Since community care was first implemented, much has been learned about factors that promote and treatments that limit aggressive/antisocial behaviour/criminality (AABC) among people with psychosis. Without the benefit of this knowledge, did mental health policy and practices that were in place as the asylums were closed inadvertently contribute to criminality? Material and methods: This article provides a narrative review of current evidence of effective treatments and management strategies to reduce AABC among patients with psychosis. Results: Reductions in AABC are associated with stable contact with psychiatric services, second-generation antipsychotic medication, clozapine for patients with schizophrenia and elevated levels of hostility and/or a history of childhood conduct disorder, abstinence from substances, avoidance of trauma, and constant monitoring of both illness symptoms and AABC. Conclusions: Failure to adopt evidence-based practices allows the problem of AABC to persist, prevents patients from experiencing independent, safe, community tenure, and puts those around them at risk. Many challenges remain, including implementing effective assessment and interventions at first-episode and convincing patients with antisocial attitudes and behaviours to participate in treatment programs to reduce AABC and to learn prosocial behaviours. [ABSTRACT FROM AUTHOR]

Intellectual disability (ID), schizophrenia spectrum disorder (SSD), bipolar disorder (BD), substance use disorder (SUD), and other mental disorders (OMDs) are associated with increased risks of criminality relative to sex-matched individuals without these conditions (NOIDMD). To resource psychiatric, addiction, and social services so as to provide effective treatments, further information is needed about the size of sub-groups convicted of crimes, recidivism, timing of offending, antecedents, and correlates. Stigma of persons with mental disorders could potentially be dramatically reduced if violence was prevented. A birth cohort of 14,605 persons was followed to age 64 using data from Swedish national health, criminal, and social registers. Percentages of group members convicted of violence differed significantly: males NOIDMD, 7.3%, ID 29.2%, SSD 38.6%, BD 30.7%; SUD 44.0%, and OMD 19.3%; females NOIDMD 0.8%, ID 7.7%, SSD 11.2%, BD 2.4%, SD 17.0%, and OMD 2.1%. Violent recidivism was high. Most violent offenders in the diagnostic groups were also convicted of non-violent crimes. Prior to first diagnosis, convictions (violent or non-violent) had been acquired by over 90% of the male offenders and two-thirds of the female offenders. Physical victimization, adult comorbid SUD, childhood conduct problems, and adolescent substance misuse were each associated with increased risks of offending. Sub-groups of cohort members with ID or mental disorders were convicted of violent and non-violent crimes to age 64 suggesting the need for treatment of primary disorders and for antisocial/aggressive behavior. Many patients engaging in violence could be identified at first contact with clinical services. [ABSTRACT FROM AUTHOR]

Conduct disorder (CD) prior to age 15 identifies a subgroup of men with severe mental illness (SMI) who present a high risk for violence that persists across the life span. The present study examined male violent offenders with SMI in a forensic hospital in Spain, comparing those with SMI+CD and those without SMI-CD on the HCR-20 and PCL:SV. Violent offenders with SMI+CD obtained higher HCR-20 and PCL: SV total scores, and much higher H and factor 2 scores as compared to those without prior CD. Men with SMI+CD present a challenge to forensic psychiatric services. [ABSTRACT FROM AUTHOR]

The HCR-20 is widely used to assess risk of violence among patients with schizophrenia. Further understanding of the accuracy and changes over time in C and R scores is needed. Using prospectively collected data on 248 men with schizophrenia, the present study found that the HCR-20 significantly predicted aggressive behavior over 24 months. The H, C, R, HCR-20 total, and final risk judgment scores were unable to predict aggressive behavior better than chance among the general psychiatric patients in the first six months after discharge. Changes in three C items, the total R score, and in three R items significantly predicted changes in aggressive behavior. [ABSTRACT FROM AUTHOR]

Anxiety disorders (ADs) have traditionally been thought to protect against criminality. The present study examined 165 adolescents in treatment for substance misuse and 234 parents. The aims were to determine the prevalence of conduct disorder (CD) co-morbid with ADs and to identify characteristics that distinguished those with CD+AD, as compared to those with only AD or CD. Adolescents and parents completed diagnostic interviews and questionnaires. Official criminal records were obtained; 53.9% of the adolescents presented CD and 45% of them presented co-morbid AD. Adolescents with CD+AD, as compared to those with only AD, were more likely to have a record of delinquency, to have been maltreated by parents, and they obtained higher scores on the Psychopathy Check List: Youth Version (PCL:YV). Adolescents with CD+AD were similar to those with CD alone as to aggressive behavior, delinquency, substance misuse and PCL:YV scores. Adolescents with CD+AD engaged in violence and antisocial behavior similar to those with CD alone. [ABSTRACT FROM PUBLISHER]

Instrumental and reactive subtypes of aggression are likely to have different biopsychosocial roots. This has implications for research aimed at identifying aetiological mechanisms and for forensic practice. In this methodological note we describe the development of a unidimensional measure of lifetime persistent instrumental aggression based on information collected from a random sample of 241 Scottish male prisoners. We applied modern psychometric methods - confirmatory factor analysis and item response theory methods - to the development of a short, reliable and informative measure of this important forensic construct. Results indicated that information from files and interviews could be combined to develop a unidimensional measure of the degree of instrumentality, which provided a psychometrically robust measure of the construct of instrumental aggression. Further, item response theory analyses indicated good measurement across the middle to high range of the trait. Identifying life-long patterns of instrumental aggressive behaviour, and distinguishing instrumental aggression from the broad pool of aggressive behaviour, has the potential to improve understanding of underlying mechanisms, increase the accuracy of risk assessments, and contribute to more effective treatment and management strategies. [ABSTRACT FROM AUTHOR]

A minority of persons with severe mental illness (SMI) engage in violence towards others. These individuals, however, constitute a heterogeneous population with respect to patterns and correlates of violence. The present study used multivariate profile analyses to identify clusters of patients with SMI who displayed similar patterns of violence and similar correlates among 178 participants with SMI and a history of interpersonal violence. The types, locations, methods, and victims of violence, the associations of psychotic symptoms, alcohol and drug intoxication with violence, psychopathy traits, and impulsivity were entered into multiple correspondence analyses. Three subgroups of violent individuals were identified: psychotic, repetitive, and institutional. A fourth, unexpected subgroup of less violent persons was also found. The subgroups differed as to frequency, type, method, and location of violent incidents towards others; the presence of delusions, hallucinations, and intoxication when violent; and levels of psychopathy traits and impulsivity. These results demonstrate that among persons with SMI and considered at risk for violence, there are subgroups who display distinctive patterns and correlates of violent behavior. The finding that factors promoting violence in the subgroups differ indicates the need for distinct treatment and management strategies to reduce violence in each type. [ABSTRACT FROM AUTHOR]

Background. Adolescents who consult for substance misuse problems are at increased risk for multiple adverse outcomes from ages 21 to 50. Method. The sample included 180 adolescents who consulted a clinic for substance misuse and 251 of their parents. Adolescents and parents completed diagnostic interviews and independently completed questionnaires reporting on maltreatment of the adolescents. The adolescents completed questionnaires on substance misuse, illegal activities and relationships with others. Information was extracted from the criminal register. Twelve months later, 86% of the adolescents again completed a diagnostic interview, responded to questions about treatments they had received and completed questionnaires as before. In addition, information was extracted from health and social service files. Results. Six problem domains were defined to include externalizing and internalizing disorders, substance misuse, and violent and non-violent self-reported offending. These were generally stable during the 12-month follow-up, but some adolescents did improve, while others developed new problems. Change in the number of problem domains over the 12-month period was predicted by the number of problem domains present at first contact with the clinic and negatively by treatment during the follow-up period. Conclusion. Adolescents who consulted for substance misuse presented multiple mental health and psychosocial problems, which had been present for many years. The multiplicity of problems largely determined outcome 12 months later. Effective interventions are needed to target each problem domain. Identification and intervention with young children presenting mental health problems are needed to avoid the accumulation of problems observed in this sample of adolescents. [ABSTRACT FROM AUTHOR]

Schizophrenia is associated with an elevated risk for violence. The response has been to incarcerate people with schizophrenia and to increase the number of forensic beds. Most of these beds are filled by men with schizophrenic disorders with long histories of offending and of treatment in general psychiatry. Outcome from forensic, as compared to general psychiatric services, is unknown. The present study compared outcome defined as levels of positive and negative symptoms, readmission, and aggressive behavior for 248 men with schizophrenic disorders (150 discharged from forensic hospitals and 98 from general adult wards) during a two-year period after discharge from forensic and general psychiatric services. Patients were intensively assessed at discharge and four times during the subsequent two years. Illicit drug use was assessed both objectively and by self-report. More of the forensic than the general patients had failed to complete high school, had displayed a stable pattern of antisocial behavior since at least mid-adolescence, and had convictions for non-violent and violent offences. At discharge and throughout the follow-up period, general patients displayed higher levels of positive and negative symptoms than forensic patients, and more of them engaged in aggressive behavior towards others. Aggressive behavior was associated with positive symptoms and Antisocial Personality Disorder. Rates of readmission were similar for the two groups. The forensic approach that includes assessing and managing the risk of violence as well as treating symptoms of schizophrenia led to better outcome than that of general psychiatry. [ABSTRACT FROM AUTHOR]

The study aimed to shed light on the recent dramatic increase in the number of forensic beds in Europe. A total of 184 patients being discharged from forensic hospitals and 122 from general psychiatry wards in sites in Canada, Finland, Germany, and Sweden were assessed and followed for two years. Information was collected from multiple sources. Forensic patients were distinguished from general psychiatric patients primarily by their histories of physical violence towards others and the trait of callousness. At discharge, the level of risk for future violence was similar among the general and forensic patients, but associated factors differed. The increase in forensic beds appears to be a response to violent behavior on the part of male patients with schizophrenia. [ABSTRACT FROM AUTHOR]

Before risk assessment instruments can be used to guide treatment, it is necessary to demonstrate accurate identification of patients at high risk for violence and of the factors associated with these behaviors for each individual. Predictors of violence vary by diagnosis, setting, and behavior being predicted. The present study examined violent and antisocial behavior of 216 patients in a forensic hospital during a one year period. The HCR-20 was completed by trained raters independent of those who collected information on antisocial and violent behavior. The HCR-20 predicted antisocial but not violent behavior. Different predictors were associated with different types of behaviors for different diagnostic groups. The HCR-20 score was highly positively correlated with patients' level of security. [ABSTRACT FROM AUTHOR]

There are well-documented associations between low verbal IQ and criminal offending and between low verbal IQ and early-onset persistent offending among males in the general population. This study was designed to test whether similar associations could be observed in a sample of 219 men with schizophrenia and schizoaffective disorder. The participants were recruited at discharge from forensic and general psychiatric hospitals in four sites in Canada, Finland, Germany and Sweden. In the weeks preceding discharge, information was collected from participants, family members, staff, and official records. The results demonstrated that low verbal IQ was not associated with the risk of criminal offending, nor with the numbers of offences, but with the age at first non-violent offence. Low verbal IQ was associated with lengthy stays in hospital that may have limited further criminal offending. [ABSTRACT FROM AUTHOR]

This article identifies research priorities for the field of forensic mental health. What is known about the association between mental disorders, retardation, brain damage and offending and violence is briefly reviewed. It is noted that while some of the correlates of offending are common to both non-disordered and disordered offenders, others characterize specific subgroups of mentally disordered offenders. The evidence is consistent in showing that most mentally disordered offenders have multiple problems that have been present, in many cases, since childhood. Knowledge about effective treatments for mentally disordered, mentally retarded, and brain damaged offenders is highlighted. It is concluded that there is a lack of information about the organization, legal powers, and content of treatment, management, and rehabilitation programs that have been shown to impact on recidivism, relapse, and autonomous functioning. Almost nothing is known about the impact of various social services. Future research should be designed to contribute to (1) improving the efficacy of models of service organization; (2) improving the efficacy of treatment, management, and rehabilitation programs; (3) improving the efficacy of the multiple components included in treatment, management, and rehabilitation programs; (4) integrating risk assessment of violent behavior into treatment, management, and rehabilitation programs and improving the accuracy of prediction; (5) identifying the etiologies of offending and violence among persons with mental disorders, mental retardation, and brain damage; and (6) preventing offending and violence among children at risk for mental disorders. [ABSTRACT FROM PUBLISHER]

Mental health professionals are required to predict “dangerousness” of patients in different situations. But it is not always clear what is ment by the term “dangerousness”. It can mean simply stating whether or not a specific patient is likely to commit a crime in the future or it can mean identifying the situation or situations in which a specific patient is more or less likely to commit a crime. Epidemiological studies of birth cohorts followed to adulthood indicate that persons with major mental disorders are at increased risk, as compared to non-disordered persons, to commit crimes and crimes of violence. Another group of individuals at high risk to commit crimes are those who meet the the diagnostic criteria for psychopathy. This disorder can now be reliably and validly diagnosed using Hare's Psychopathy Checklist-Revised (PCL-R). Recently, procedures have been developed which allow for relatively accurate predictions of illegal behaviour. These procedures (sometimes referred to as prediction schemes) are specific to different types of persons—the mentally ill, the psychopath, the sex offender, etc. The predictive accuracy of these procedures depends on the collection of high quality objective information, both historical and current. [ABSTRACT FROM AUTHOR]

There is now compelling evidence of high rates of criminality and violence among both men and women who suffer from major mental disorders. This evidence comes from prospective follow-up studies of unselected birth cohorts, from follow-up studies of psychiatric patients discharged to the community, and from studies of mental disorders among convicted offenders. These investigations have been conducted in several different countries since policies of deinstitutionalizing the mentally disordered have been implemented. Different explanations of the criminality of subjects with major mental disorders are discussed and evaluated. It is proposed that there are two types of offenders with major mental disorders: the early starter displays a stable pattern of antisocial behaviour from a young age; the late starter begins offending only at about the time the symptoms of the major disorder become apparent. It is hypothesized that the major disorder is not related to the criminality of the early starters, while the symptoms of the disorder may be directly related to the illegal behaviours of the late starters. [ABSTRACT FROM PUBLISHER]