Early risk factors for criminal offending in schizophrenia: a 35-year longitudinal cohort study

Association of Schizophrenia Spectrum Disorders and Violence Perpetration in Adults and Adolescents From 15 Countries: A Systematic Review and Meta-analysis

IMPORTANCE

Violence perpetration outcomes in individuals with schizophrenia spectrum disorders contribute to morbidity and mortality at a population level, disrupt care, and lead to stigma.

OBJECTIVE

To conduct a systematic review and meta-analysis of the risk of perpetrating interpersonal violence in individuals with schizophrenia spectrum disorders compared with general population control individuals.

DATA SOURCES

Multiple databases were searched for studies in any language from January 1970 to March 2021 using the terms violen* or homicid* and psychosis or psychoses or psychotic or schizophren* or schizoaffective or delusional and terms for mental disorders. Bibliographies of included articles were hand searched.

STUDY SELECTION

The study included case-control and cohort studies that allowed risks of interpersonal violence perpetration and/or violent criminality in individuals with schizophrenia spectrum disorders to be compared with a general population group without these disorders.

DATA EXTRACTION AND SYNTHESIS

The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and the Meta-analyses of Observational Studies in Epidemiology (MOOSE) proposal. Two reviewers extracted data. Quality was assessed using the Newcastle-Ottawa Quality Assessment Scale. Data were pooled using a random-effects model.

MAIN OUTCOMES AND MEASURES

The main outcome was violence to others obtained either through official records, self-report and/or collateral-report, or medical file review and included any physical assault, robbery, sexual offenses, illegal threats or intimidation, and arson.

RESULTS

The meta-analysis included 24 studies of violence perpetration outcomes in 15 countries over 4 decades (N = 51 309 individuals with schizophrenia spectrum disorders; reported mean age of 21 to 54 years at follow-up; of those studies that reported outcomes separately by sex, there were 19 976 male individuals and 14 275 female individuals). There was an increase in risk of violence perpetration in men with schizophrenia and other psychoses (pooled odds ratio [OR], 4.5; 95% CI, 3.6-5.6) with substantial heterogeneity (I2 = 85%; 95% CI, 77-91). The risk was also elevated in women (pooled OR, 10.2; 95% CI, 7.1-14.6), with substantial heterogeneity (I2 = 66%; 95% CI, 31-83). Odds of perpetrating sexual offenses (OR, 5.1; 95% CI, 3.8-6.8) and homicide (OR, 17.7; 95% CI, 13.9-22.6) were also investigated. Three studies found increased relative risks of arson but data were not pooled for this analysis owing to heterogeneity of outcomes. Absolute risks of violence perpetration in register-based studies were less than 1 in 20 in women with schizophrenia spectrum disorders and less than 1 in 4 in men over a 35-year period.

CONCLUSIONS AND RELEVANCE

This systematic review and meta-analysis found that the risk of perpetrating violent outcomes was increased in individuals with schizophrenia spectrum disorders compared with community control individuals, which has been confirmed in new population-based longitudinal studies and sibling comparison designs.

Young age and the risk of violent behaviour in people with severe mental disorders: prospective, multicentre study

Background

During adolescence and young adulthood people appear to be more prone to violent behaviour. A greater tendency to violent behaviour appears to be associated with hyperactivity, impulsivity and low tolerance for frustration and provocation in social settings.

Aims

This prospective cohort study aimed to evaluate rates of violent behaviour among young people with mental disorders, compared with older age groups.

Method

A total of 340 individuals with severe mental disorders (125 living in residential facilities and 215 out-patients) were evaluated at baseline with the SCID-I and II, Brief Psychiatric Rating Scale, Specific Level of Functioning scale, Brown–Goodwin Lifetime History of Aggression scale, Buss–Durkee Hostility Inventory, Barratt Impulsiveness Scale and State–Trait Anger Expression Inventory-2. Aggressive behaviour was rated every 15 days with the Modified Overt Aggression Scale (MOAS).

Results

The sample comprised 28 individuals aged 18–29 years, 202 aged 30–49 and 110 aged 50 and over. Younger age was associated with a personality disorder diagnosis, substance use disorder, being single and employed. These results were confirmed even controlling for the gender effect. The patterns of the cumulative MOAS mean scores showed that younger (18–29 years old) individuals were significantly more aggressive than older (≥50) ones (P < 0.001).

Conclusions

This study highlights how young age in people with severe mental disorders is correlated with higher levels of impulsivity, anger and hostility, confirming previous analyses. Our results may assist clinicians in implementing early interventions to improve anger and impulsivity control to reduce the risk of future aggressive behaviours.

Homicides committed by delusional patients in the early 20th and 21st centuries: A study conducted in a French secure unit

Homicides committed by delusional patients are the object of a rich scientific literature, which puts the risk of such acts occurring into perspective when analyzing the offenders' sociodemographic and clinical characteristics. However, few articles detail the themes and mechanisms underlying those patients' delusions. To help bridge that gap, the authors conducted this retrospective descriptive study, including two samples of delusional homicidal patients, one from near present day and one from nearly a century ago. This study considered similarities observed in the literature (such as patients' sociodemographic profile, clinical data, and acting-out dynamics), but also explored the characteristics of delusion. In the 2015-2019 sample, the typical patient profile was: single male (31.5 years old on average), without child, unemployed, and with psychiatric history (56.6%). Most patients suffered from schizophrenic disease (83%) with non-systematized delusions exhibiting multiple themes in 80% of cases. Four principal types of delusion were observed: persecutive (100%), mystical (43.3%), megalomaniac (30%), and bodily (30%). The mechanisms were interpretative, hallucinatory, and intuitive. There was a societal influence in 23.3% of the cases (most often terrorist acts). The 1910-1914 historical sample revealed several differences: patients were older, more often married and employed. There were more diagnoses of chronic delusional disorder (30%). Persecutory delusion was constant (100%), and the other delusional themes were the "intimate relationship" type (50%)-jealousy, erotomanic-and the bodily type (40%). Additional studies are useful in order to reinforce our findings, and to further investigate the possibilities of prevention.

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.

Comparative study of aggression - Dangerousness on patients with paranoid schizophrenia: Focus on demographic data, PANSS, drug use and aggressiveness

This cross sectional study aimed to compare the differences in psychopathology of Greek homicide and homicide attempters, patients with schizophrenia, with non violent individuals, suffering from schizophrenia. The study compared three Groups of 220 men, diagnosed with schizophrenia: (a) Group Α (Schizophrenia - No violence, (b) Group Β (Schizophrenia - with violence or violent crime), (c) Group C (Schizophrenia - not guilty by reason of insanity - violent crime). Several psychometric tools were used, such as M.I.N·I (Mini-International Neuropsychiatric Interview), PANSS scale (Positive and Negative Symptoms Scale). Most subjects suffered from paranoid schizophrenia. On factors such as demographic characteristics (i.e. current occupational status, living status), statistically significant findings were shown for Groups B and C vs Group A. Predisposing psychosocial factors, such as family conflicts and aggressiveness against family, were found to be statistically significant in differentiating violent versus nonviolent individuals with psychosis. They differed significantly in factors like history of juvenile delinquency, but also in the type of aggressiveness in general. These differences were confirmed on PANSS scale. In conclusion, the longer the history of aggressiveness is presented, the greater the chances are of individuals falling into Group C and it is possible to spend several years from the onset of the disease until the moment of crime.

Antecedents, Behaviours, and Court Case Characteristics and Their Effects on Case Outcomes in Litigation for Persons with Schizophrenia

A 10% random sample of 3543 cases litigated in the United States' civil and criminal courts were analysed using logistic regression to develop a model that can predict case outcomes for litigants with schizophrenia. Most predictors are related to case characteristics and not to the litigants' antecedents, behaviours or medication issues. Only the psychologist as an expert witness was found to be related to case outcome, but the concern is expressed that inadequate weight is given to expert testimony. Other significant findings include being represented by counsel, atypical medication and malingering.

Psychiatric monitoring of not guilty by reason of insanity outpatients

Individuals deemed Not Guilty by Reason of Insanity (NGRI) by the courts, under Article 20 of the Portuguese Criminal Code, have often committed very serious crimes. It is unreasonable to consider that these patients were usually kept without adequate supervision after the security measure had been declared extinct. They often decompensated after leaving the institution where they complied with the security measure, and/or relapsed to alcohol and drug abuse. Very often, severe repeated crime erupted again. Considering this, there was an urgent need to keep a follow-up assessment of these patients in order to prevent them from relapsing in crime. This work presents the results of a psychiatric follow-up project with NGRI outpatients. The main goals of the project were: ensuring follow-up and appropriate therapeutic responses for these patients, maintaining all individuals in a care network, and preventing them from decompensating. The team consisted of a psychiatrist, a nurse, and a psychologist. Seventy-two patients were monitored during two years. Results demonstrated the unequivocal need to follow up decompensated patients after the court order is extinguished. Suggestions are presented for a better framing and psychiatric follow-up of these patients.

Psychiatric and neurological disorders in late adolescence and risk of convictions for violent crime in men

BACKGROUND

The relationship between mental illness and violent crime is complex because of the involvement of many other confounding risk factors. In the present study, we analysed psychiatric and neurological disorders in relation to the risk of convictions for violent crime, taking into account early behavioural and socio-economic risk factors.

METHODS

The study population consisted of 49,398 Swedish men, who were thoroughly assessed at conscription for compulsory military service during the years 1969-1970 and followed in national crime registers up to 2006. Five diagnostic groups were analysed: anxiety-depression/neuroses, personality disorders, substance-related disorders, mental retardation and neurological conditions. In addition, eight confounders measured at conscription and based on the literature on violence risk assessment, were added to the analyses. The relative risks of convictions for violent crime during 35 years after conscription were examined in relation to psychiatric diagnoses and other risk factors at conscription, as measured by odds ratios (ORs) and confidence intervals (CIs) from bivariate and multivariate logistic regression analyses.

RESULTS

In the bivariate analyses there was a significant association between receiving a psychiatric diagnosis at conscription and a future conviction for violent crime (OR = 3.83, 95 % CI = 3.47-4.22), whereas no significant association between neurological conditions and future violent crime (OR = 1.03, 95 % CI = 0.48-2.21) was found. In the fully adjusted multivariate logistic regression model, mental retardation had the strongest association with future violent crime (OR = 3.60, 95 % CI = 2.73-4.75), followed by substance-related disorders (OR = 2.81, 95 % CI = 2.18-3.62), personality disorders (OR = 2.66, 95 % CI = 2.21-3.19) and anxiety-depression (OR = 1.29, 95 % CI = 1.07-1.55). Among the other risk factors, early behavioural problem had the strongest association with convictions for violent crime.

CONCLUSIONS

Mental retardation, substance-related disorders, personality disorders and early behavioural problems are important predictors of convictions for violent crime in men.

Violent and non-violent methods of attempted and completed suicide in Swedish young men: the role of early risk factors

BACKGROUND

There is a paucity of studies on the role of early risk factors for the choice of methods for violent suicide attempts. Adolescent risk factors for the choice of violent or non-violent methods for suicide attempts and the risk of subsequent suicide were studied using a longitudinal design.

METHODS

A national Swedish cohort of 48 834 18-20-year-old young men conscripted for military service from 1969 to 1970 was followed through official registers during a 37-year period. Two questionnaires concerning their psychosocial background were answered by each conscript. Cox proportional hazard regression analyses were used to estimate the risk for different methods of attempted suicide and later suicide.

RESULTS

A total of 1195 (2.4 %) men had made a suicide attempt and of these, 133 (11.1 %) committed suicide later. The number of suicide victims among the non-attempters was 482 (1 %). Half of the suicides occurred during the same year as the attempt. Suicide victims had earlier onset of suicidal behaviour and had more often used hanging as a method of attempted suicide than those who did not later commit suicide. The early risk factors for both violent and non-violent methods of suicide attempt were quite similar.

CONCLUSION

Violent suicide attempts, especially by hanging, are associated with a clearly elevated suicide risk in men and require special clinical and public health attention. The early risk factors related to the choice of either a violent or a non-violent suicide attempt method are interlinked and circumstantial factors temporally close to the suicide attempt, such as access to a specific method, may partly explain the choice of method.

Schizophrenia and violent crime: a population-based study

BACKGROUND

Previous studies have found that patients with schizophrenia are more likely to be violent than the general population. The aim of this study was to investigate the association between schizophrenia and violent crime in the Israeli population.

METHOD

Using the Israeli Psychiatric Hospitalization Case Registry we identified 3187 patients with a discharge diagnosis of schizophrenia. For each proband we identified parents and siblings, and gender- and age-matched controls for patients, parents and siblings. Information on violent crimes was obtained from police records.

RESULTS

Patients with schizophrenia were at increased risk for violent crimes compared with controls [odds ratio (OR) 4.3, 95% confidence interval (CI) 3.8-4.9], especially women (OR 9.9, 95% CI 6.2-15.7). Risk for violent crimes was higher among patients with co-morbid substance misuse than in patients without such co-morbidity (OR 5.1, 95% CI 4.2-6.3).

CONCLUSIONS

The results of this study suggest that increased risk of violence is part of the clinical picture of schizophrenia and needs to be recognized as a legitimate, essential, aspect of clinical management.

Criminality and suicide: a longitudinal Swedish cohort study

OBJECTIVES

This study aimed to investigate whether violent and non-violent offending were related to elevated risk of suicide. We also investigated whether the risk was higher among those with repeated offences and how experiences of substance misuse and suicide attempt modified the relationship.

DESIGN

A nationwide prospective cohort study.

SETTING

A register study of 48 834 conscripted men in 1969/1970 in Sweden followed up during a 35-year period in official registers.

PARTICIPANTS

A birth cohort of 48 834 men who were mandatory conscripted for military service in 1969/70 at the age of 18-20 years. Possible confounders were retrieved from psychological assessments at conscription and the cohort was linked to mortality and hospitalisation and crime records from 1970 onwards. Estimates of suicide risks were calculated as HR with 95% CIs using Cox proportional regression analyses with adjustment for potential confounding by family, psychological and behavioural factors including substance use and psychiatric disorders.

RESULTS

Of the total cohort, 2671 (5.5%) persons died during the follow-up period. Of these, 615 (23%) persons died due to suicide. Non-violent criminality was evident for 29% and violent criminality for 4.7% of all the participants. In the crude model, the violent offenders had nearly five times higher risk (HR=4.69, 3.56 to 6.19) to die from suicide and non-violent criminals had about two times higher risk (HR=2.08, 1.72 to 2.52). In the fully adjusted model, the HRs were still significant for suicide in the non-violent group.

CONCLUSIONS

Experiences of violent or non-violent criminality were associated with increased risk of suicide. Comorbidity with alcohol and substance use and psychiatric disorders modified the risk, but the suicide risk remained significantly elevated for non-violent criminals. It is crucial to identify offenders and especially repeated offenders who also suffer from alcohol or substance misuse and psychiatric illness in clinical settings in order to prevent suicide.

Neurocognitive vulnerability: suicidal and homicidal behaviours in patients with schizophrenia

OBJECTIVE

Schizophrenia is associated with an increase in the risk of both homicide and suicide. The objectives of this study were to systematically review all published articles that examined the relation between neurocognitive deficits and suicidal or homicidal behaviours in schizophrenia, and to identify vulnerabilities in suicidal and homicidal behaviour that may share a common pathway in schizophrenia.

METHODS

A systematic review of the literature was performed using MEDLINE to include all studies published up to August 31, 2012.

RESULTS

Among the 1760 studies, 7 neuropsychological and 12 brain imaging studies met the selection criteria and were included in the final analysis. The neuropsychological and functional neuroimaging studies were inconclusive. The structural imaging studies reported various alterations in patients with schizophrenia and a history of homicidal behaviour, including: reduced inferior frontal and temporal cortices, increased mediodorsal white matter, and increased amygdala volumes. Patients with a history of suicidal acts showed volumetric reductions in left orbitofrontal and superior temporal cortices, while right amygdala volume was increased, though, these findings have rarely been replicated. Finally, no study has directly compared neurocognitive markers of suicidal and homicidal risk.

CONCLUSION

These results suggest that brain alterations, in addition to those associated with schizophrenia, may predispose some patients to a higher risk of homicide or suicide in particular circumstances. Moreover, some of these alterations may be shared between homicidal and suicidal patients. However, owing to several limitations, including the small number of available studies, no firm conclusions can be drawn and further investigations are necessary.

[Homicide, schizophrenia and substance abuse: a complex interaction]

BACKGROUND AND AIM

The prevalence of homicide perpetrators with a diagnosis of schizophrenia is 6% in Western countries populations. The relationship between schizophrenia and homicide is complex and cannot be reduced to a simple causal link. The aim of this systematic review was to clarify the role of substance abuse in the commission of murder in people suffering from schizophrenia.

METHODS

A systematic English-French Medline and EMBASE literature search of cohort studies, case-control studies and transversal studies published between January 2001 and December 2011 was performed, combining the MeSH terms "schizophrenia", "psychotic disorders", "homicide", "violence", "substance use disorder", and the TIAB term "alcohol". Abstract selection was based on the STROBE and PRISMA checklist for observational studies and systematic and meta-analysis studies, respectively.

RESULTS

Of the 471 selected studies, eight prospective studies and six systematic reviews and meta-analysis studies met the selection criteria and were included in the final analysis. Homicide committed by a schizophrenic person is associated with socio-demographic (young age, male gender, low socioeconomic status), historical (history of violence against others), contextual (a stressful event in the year prior to the homicide), and clinical risk factors (severe psychotic symptoms, long duration of untreated psychosis, poor adherence to medication). In comparison to the general population, the risk of homicide is increased 8-fold in schizophrenics with a substance abuse disorder (mainly alcohol abuse) and 2-fold in schizophrenics without any comorbidities. A co-diagnosis of substance abuse allows us to divide the violent schizophrenics into "early-starters" and "late-starters" according to the age of onset of their antisocial and violent behavior. The violence of the "early-starters" is unplanned, usually affects an acquaintance and is not necessarily associated with the schizophrenic symptoms. Substance abuse is frequent and plays an important role in the homicide commission. In addition, the risk of reoffending is high. In the "late-starters", the violence is linked to the psychotic symptoms and is directed to a member of the family. The reoffence risk is low and it depends on the pursuit of care or not.

CONCLUSION

Defining subgroups of violent schizophrenic patients would avoid stigmatization and would help to prevent the risk of homicide by offering a multidisciplinary care which would take into account any substance abuse.

Estimated rates of mental disorders in, and situational characteristics of, incidents of nonfatal use of force by police

PURPOSE

To examine the estimated rates of mental disorders and associated situational characteristics in people involved in nonfatal use of force incidents with police in VIC, Australia.

METHODS

A random sample of 4,267 cases between 1995 and 2008 from a dedicated police Use of Force Register were linked with the state-wide public mental health database and a police contacts database. Rates of ICD 9 and ICD 10 mental disorders recorded on the public mental health database were examined, as well as rates of criminal offending and the characteristics of force used by both parties.

RESULTS

More than a third of people on whom the police resorted to using force (n = 1,621, 38%) had a history of mental disorder. Significant overrepresentations of the estimated prevalence of psychosis [12.5%, OR = 9.03, 95% CI (7.41, 11.01), p < 0.001] and schizophrenia [9.1%, OR = 9.73, 95% CI (7.59, 12.47) p < 0.001] were found. Those diagnosed with mental disorders were 1.52 times more likely to use or threaten to use weapons on police, even after taking into account age, sex, substances intoxication and violent behaviour [95% CI (1.23, 1.91), p < 0.001]; however, they were no more likely to injure or be injured by police than those without a recorded history of mental disorder. There was a noted trend for police to use, or threaten to use, weapons on people with a history of psychosis (other than schizophrenia) [OR = 1.40, 95% CI (1.11, 1.78), p = 0.005].

CONCLUSIONS

Psychoses and schizophrenia are dramatically overrepresented in cases where police resort to using force. Situational characteristics evident in the encounters are suggestive of a sub-group of people with mental disorders presenting with aggressive and otherwise problematic behaviours coupled with histories of criminal offending; this presents significant ongoing challenges for the police.

Foster care, residential care and public care placement patterns are associated with adult life trajectories: population-based cohort study

OBJECTIVES

Childhood experiences of public care may be associated with adult psychosocial outcomes. This study aimed to evaluate the associations of four public care exposures: type of placement, length of placement, age at admission to care and number of placements, as well as the reasons for admission to public care with emotional and behavioural traits at age 30 years.

METHODS

Participants included 10,895 respondents at the age 30 survey of the 1970 British Cohort Study (BCS70) who were not adopted and whose care history was known. Analyses were adjusted for individual, parental and family characteristics in childhood.

RESULTS

Cohort members with a public care experience presented lower childhood family socio-economic status compared with those in the no public care group. After adjusting for confounding, exposure to both foster and residential care, longer placements and multiple placements were associated with more extensive adult emotional and behavioural difficulties. Specifically, residential care was associated with increased risk of adult criminal convictions (OR = 3.09, 95% CI: 2.10-4.55) and depression (1.81, 1.23-2.68). Multiple placements were associated with low self-efficacy in adulthood (OR = 3.57, 95% CI: 2.29, 5.56). Admission to care after the age of 10 was associated with increased adult criminal convictions (OR = 6.03, 95% CI: 3.34-10.90) and smoking (OR = 3.32, 95% CI: 1.97-5.58).

CONCLUSION

Adult outcomes of childhood public care reflect differences in children's experience of public care. Older age at admission, multiple care placements and residential care may be associated with worse outcomes.

Mental disorder and violence: is there a relationship beyond substance use?

PURPOSE

A general consensus exists that severe mental illness (SMI) increases violence risk. However, a recent report claimed that SMI "alone was not statistically related to future violence in bivariate or multivariate analyses." We reanalyze the data used to make this claim with a focus on causal relationships between SMI and violence, rather than the statistical prediction of violence.

METHODS

Data are from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a two-wave study (N = 34,653: Wave 1: 2001-2003; Wave 2: 2004-2005). Indicators of mental disorder in the year prior to Wave 1 were used to examine violence between Waves 1 and 2.

RESULTS

Those with SMI, irrespective of substance abuse status, were significantly more likely to be violent than those with no mental or substance use disorders. This finding held in both bivariate and multivariable models. Those with comorbid mental and substance use disorders had the highest risk of violence. Historical and current conditions were also associated with violence, including childhood abuse and neglect, household antisocial behavior, binge drinking and stressful life events.

CONCLUSIONS

These results, in contrast to a recently published report, show that the NESARC data are consistent with the consensus view on mental disorder and violence: there is a statistically significant, yet modest relationship between SMI (within 12 months) and violence, and a stronger relationship between SMI with substance use disorder and violence. These results also highlight the importance of premorbid conditions, and other contemporaneous clinical factors, in violent behavior.