Post-illness-onset risk of offending across the full spectrum of psychiatric disorders

Mental and physical health morbidity among people in prisons: an umbrella review

BACKGROUND

People who experience incarceration are characterised by poor health profiles. Clarification of the disease burden in the prison population can inform service and policy development. We aimed to synthesise and assess the evidence regarding the epidemiology of mental and physical health conditions among people in prisons worldwide.

METHODS

In this umbrella review, five bibliographic databases (Web of Science, PubMed, PsycINFO, Embase, and Global Health) were systematically searched from inception to identify meta-analyses published up to Oct 31, 2023, which examined the prevalence or incidence of mental and physical health conditions in general prison populations. We excluded meta-analyses that examined health conditions in selected or clinical prison populations. Prevalence data were extracted from published reports and study authors were contacted for additional information. Estimates were synthesised and stratified by sex, age, and country income level. The robustness of the findings was assessed in terms of heterogeneity, excess significance bias, small-study effects, and review quality. The study protocol was pre-registered with PROSPERO, CRD42023404827.

FINDINGS

Our search of the literature yielded 1909 records eligible for screening. 1736 articles were excluded and 173 full-text reports were examined for eligibility. 144 articles were then excluded due to not meeting inclusion criteria, which resulted in 29 meta-analyses eligible for inclusion. 12 of these were further excluded because they examined the same health condition. We included data from 17 meta-analyses published between 2002 and 2023. In adult men and women combined, the 6-month prevalence was 11·4% (95% CI 9·9-12·8) for major depression, 9·8% (6·8-13·2) for post-traumatic stress disorder, and 3·7% (3·2-4·1) for psychotic illness. On arrival to prison, 23·8% (95% CI 21·0-26·7) of people met diagnostic criteria for alcohol use disorder and 38·9% (31·5-46·2) for drug use disorder. Half of those with major depression or psychotic illness had a comorbid substance use disorder. Infectious diseases were also common; 17·7% (95% CI 15·0-20·7) of people were antibody-positive for hepatitis C virus, with lower estimates (ranging between 2·6% and 5·2%) found for hepatitis B virus, HIV, and tuberculosis. Meta-regression analyses indicated significant differences in prevalence by sex and country income level, albeit not consistent across health conditions. The burden of non-communicable chronic diseases was only examined in adults aged 50 years and older. Overall, the quality of the evidence was limited by high heterogeneity and small-study effects.

INTERPRETATION

People in prisons have a specific pattern of morbidity that represents an opportunity for public health to address. In particular, integrating prison health within the national public health system, adequately resourcing primary care and mental health services, and improving linkage with post-release health services could affect public health and safety. Population-based longitudinal studies are needed to clarify the extent to which incarceration affects health.

FUNDING

Research Foundation-Flanders, Wellcome Trust, National Institutes of Health.

Elusive cases in forensic psychiatry? Exploring subgroups of schizophrenia spectrum disorder patients in Germany

BACKGROUND

The relationship between schizophrenia spectrum disorders (SSD) and criminal behaviour is a central issue in forensic psychiatry. People with mental illness face some of the same types of criminogenic factors as people without mental illness, albeit more frequently. The research question of this study is the extent to which a framework of early and late offender typology can be empirically reconstructed in a forensic psychiatric population, and whether there are any practical implications.

METHOD

For N = 733 patients in six different forensic hospitals in Germany, the age at first psychiatric admission and the age at first registered offence were documented, as well as a number of other patient-related characteristics. Two clustering procedures were used to investigate whether forensic psychiatric patients could be classified according to these characteristics.

RESULTS

A k-means cluster analysis using age at first psychiatric admission, age at first recorded offence, sociodemographic, clinical and criminological characteristics supported a 4-cluster solution. MANOVA analyses revealed further differences between the identified types.

CONCLUSION

This study empirically confirms some of the sub-groups of the early and late starter typology described in the literature. In particular, the "early starters", "late starters" and "first presenters" were identified, but cluster four comprises individuals not previously described in the scientific literature. Each of these classes has group-specific characteristics that may have implications for forensic treatment, post-release aftercare, and the legal system.

Absolute and relative risk of violent victimisation and perpetration following onset of mental illness: a Danish register-based study

Background

Previous research has suggested that people with severe mental illness are at elevated risk of both violence perpetration and violent victimisation, with risk of the latter being perhaps greater than the former. However, few studies have examined risk across both outcomes.

Methods

Using a total population approach, the absolute and relative risks of victimisation and perpetration were estimated for young men and women across the full psychiatric diagnostic spectrum. Information on mental disorder status was extracted from national registers and information on violent victimisation and perpetration outcomes from police records. The follow-up was from age 15 to a maximum of 31 years, with most of the person-time at risk pertaining to cohort members aged in their early twenties. Both absolute risk (at 1 and 5 years from onset of illness) and relative risk were estimated.

Findings

Both types of violent outcome occurred more frequently amongst those with mental illness than the general population. However, whether risk of one was greater than the other depended on a range of factors, including sex and diagnosis. Men with a mental disorder had higher absolute risks of both outcomes than women [victimisation: Cin (5 year) = 7.15 (6.88-7.42) versus Cin (5 year) = 4.79 (4.61-4.99); perpetration: Cin (5 year) = 8.17 (7.90-8.46) versus Cin (5 year) = 1.86 (1.75-1.98)], as was the case with persons in the general population without a recorded mental illness diagnosis. Women with mental illness had higher absolute risk of victimisation than perpetration, which was also true for men and women without mental illness. However, the opposite was true for men with mental illness. Men and women with diagnoses of personality disorders, substance use disorders, and schizophrenia-spectrum disorders were at highest risk of victimisation and perpetration.

Interpretation

Strategies developed to prevent violent victimisation and violence perpetration may need to be tailored for young adults with mental disorders. There may also be a benefit in taking a sex-specific approach to prevention in this group.

Funding

This study was supported by an Australian National Health and Medical Research Council Investigator Grant awarded to the first author.

Depressive symptoms and anger and aggression in Russian adolescents

Research among adolescents exploring the association between depressive symptoms and aggression has produced inconsistent findings. This study investigated the prevalence of clinically significant (current major depressive episode) and subthreshold depressive symptoms in a general population sample of adolescents from Northern Russia and explored their association with aggression and anger, while controlling for comorbid mental health problems. The sample consisted of 2600 participants, aged 13-17 years (59.5% female; 95.7% ethnic Russian). Symptoms of a current major depressive episode, types of anger and aggression (anger rumination, trait anger, physical, verbal and social aggression) and comorbid problems (posttraumatic stress, alcohol use, anxiety, and hyperactivity/impulsivity) were assessed by means of self-reports. The prevalence of a clinically significant depressive episode in the past month was 3.5%, while for subthreshold depression it was 21.6%. All anger and aggression variables, as well as comorbid problems increased together with increasing levels of depression. The association between overt aggressive behavior and depression was primarily explained by comorbid mental health problems, whereas anger rumination and social aggression had more direct associations with depression, independent of comorbidity. Among adolescents with depression, boys reported higher levels of social and verbal aggression and of anger rumination than girls. The results of this study suggest that interventions aiming to reduce aggressive behavior in adolescents should consider depression and its comorbid conditions.

Cognitive and clinical characteristics of offenders and non-offenders diagnosed with schizophrenia spectrum disorders: results of the Recoviwel observational study

The association between schizophrenia spectrum disorders (SSD) and violent behavior is complex and requires further research. The cognitive correlates of violent behavior, in particular, remain to be further investigated. Aims of the present study were to comprehensively assess the cognitive and clinical profile of SSD violent offenders and evaluate individual predictors of violent behavior. Fifty inmates convicted for violent crimes in a forensic psychiatry setting and diagnosed with SSD were compared to fifty non-offender patients matched for age, gender, education, and diagnosis. Offender and non-offender participants were compared based on socio-demographic, clinical, and cognitive variables using non-parametric testing to select potential predictors of violent behavior. Multivariate logistic regressions were then performed to identify individual predictors of violent behavior. Offender participants showed more school failures, higher prevalence of substance use, higher Clinical Global Impression Severity Scale (CGI-S) and Positive and Negative Syndrome Scale Excited Component (PANSS-EC) scores, worse working memory and better attention performance, higher Historical Clinical and Risk Management scale 20 (HCR-20) and Hare Psychopathy Checklist (PCL-R) scores in all subdomains and factors. School failures, higher PANSS-EC scores, worse working memory and processing speed, better attention performance, higher scores in HCR-20 Management subscale and the PCL-R "Callous" factor emerged as predictors of violent behavior. Better attentional performance was correlated with higher PCL-R "Callous" factor scores, worse cognitive performance in several domains with higher PCL-R "Unstable" factor scores. In conclusion, the present study highlights the importance of carefully assessing SSD patients with violent behavior in all clinical, cognitive, and behavioral aspects.

Association of intellectual disability with violent and sexual crime and victimization: a population-based cohort study

BACKGROUND

Intellectual disability (ID) is associated with violent and sexual offending and victimization, but the importance of neuropsychiatric comorbidity and severity of disability remains unclear.

METHODS

In a register-based cohort study of people born in Sweden 1980-1991 (n = 1 232 564), we investigated associations of mild and moderate/severe ID with any, violent and sexual crimes, and with assault victimization, stratified by comorbid autism and attention deficit hyperactivity disorder (ADHD). We defined ID by attendance at a special school or registered diagnosis and obtained data on criminal convictions and injuries or deaths due to assaults from nationwide registers until end of 2013.

RESULTS

Compared to people without ID, autism or ADHD, men and women with mild or moderate/severe ID and comorbid ADHD had elevated risks of violent crimes [range of hazard ratios (HRs) 4.4-10.4] and assault victimization (HRs 2.0-7.7). Women with mild ID without comorbidities or with comorbid autism also had elevated risks of violent crimes and victimization (HRs 1.8-4.6) compared to women without ID, autism or ADHD. The relative risks of sexual offending and victimization were elevated in men and women with ID without comorbidities (HRs 2.6-12.7). The highest risks for sexual offending in men (HRs 9.4-11.0) and for sexual assault victimization in women (HRs 11.0-17.1) related to ID and comorbid ADHD.

CONCLUSIONS

The elevated risk of violent offending and assault victimization in people with ID is largely explained by comorbid ADHD, whereas ID is independently associated with sexual crimes and victimization, even though absolute risks are low.

The prevalence of self-reported mental illness among those imprisoned in New South Wales across three health surveys, from 2001 to 2015

OBJECTIVE

The prevalence of mental illness among those in prison is much higher than in the community; however, very few studies have examined whether rates have changed over time, in line with increasing self-reported rates in the community.

METHODS

This study compares the prevalence of self-reported mental illness, self-harm and suicidal thoughts/behaviours, and drug and alcohol use across three waves (2001, 2009 and 2015) of health surveys involving men and women in New South Wales prisons and compared these rates with published community-level findings.

RESULTS

The prevalence of those reporting any mental health diagnosis increased significantly across the three surveys, even after adjustment for socio-demographic and criminal justice variables that also changed over time. Individuals surveyed in 2015 were more likely to report a mental health diagnosis than those surveyed in 2001 (adjusted odds ratio = 2.66, 95% confidence interval = [2.16, 3.27]). The prevalence of self-harm and suicidal thoughts and behaviours remained stable across the three surveys, while self-reported regular drug use decreased over the period. Women experienced a far greater burden of mental illness than men across all three surveys and experienced more growth in the prevalence of most psychiatric disorders.

CONCLUSION

These findings have important implications for public and prison health systems given the poor social, health and criminal justice outcomes of those imprisoned with mental illness, both in custody and post-release.

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.

Individuals with schizophrenia who act violently towards others profit unequally from inpatient treatment-Identifying subgroups by latent class analysis

BACKGROUND

People with schizophrenia show a higher risk of committing violent offenses. Previous studies indicate that there are at least three subtypes of offenders with schizophrenia.

OBJECTIVES

Employing latent class analysis, the goals of this study were to investigate the presence of homogeneous subgroups of offender patients in terms of remission in psychopathology during inpatient treatment and whether or not these are related to subtypes found in previous studies. Results should help identify patient subgroups benefitting insufficiently from forensic inpatient treatment and allow hypotheses on possibly more suitable therapy option for these patients.

METHODS

A series of latent class analyses was used to explore extensive and detailed psychopathological reports of 370 offender patients with schizophrenia before and after inpatient treatment.

RESULTS

A framework developed by Hodgins to identify subgroups of offenders suffering from schizophrenia is useful in predicting remission of psychopathology over psychiatric inpatient treatment. While "early starters" were most likely to experience remission of psychopathology over treatment, "late late starters" and a subgroup including patients from all three of Hodgins' subgroups in equal proportions benefited least. Negative symptoms generally seemed least likely to remit.

CONCLUSION

Psychiatric treatment may have to be more tailored to offender patient subgroups to allow them to benefit more equally.

Incidence of Early Police Contact Among Children With Emerging Mental Health Problems in Australia

IMPORTANCE

In adulthood and adolescence, mental health vulnerability is known to be associated with risk of criminal justice system contact as both a perpetrator and survivor of crime, but whether this association is apparent early in child development is unknown. Prevention of poor outcomes, including repeated contact with the criminal justice system, relies on the identification of vulnerability early in life and at the start of such contact.

OBJECTIVE

To ascertain whether children with emotional or behavioral problems and general developmental vulnerabilities are at an increased risk of subsequent contact with police as a person of interest, a survivor of crime, or a witness.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used routinely collected data from the New South Wales Child Development Study in Australia. The cohort was composed of children who entered full-time schooling in New South Wales in 2009, had complete data for the emotional maturity domain of the Australian Early Development Census, and had no police contact before January 1, 2009. The children in the cohort were followed up until the age of 13 years. Data were analyzed from October 17, 2019, to May 13, 2020.

EXPOSURES

Emotional or behavioral problems and developmental risk profiles derived from the teacher-rated Australian Early Development Census.

MAIN OUTCOMES AND MEASURES

Incidence rates of police contact (as a person of interest, survivor of crime, or witness) were derived from the New South Wales Police Force Computerised Operational Policing System.

RESULTS

A total of 79 801 children (40 584 boys [50.9%]; 2009 mean [SD] age, 5.2 [0.37] years) were included. Children with teacher-identified emotional or behavioral problems at school entry had an incidence rate of police contact (for any reason) that was twice that of children without such problems (unadjusted hazard ratio [HR], 2.14; 95% CI, 1.94-2.37). Contact with police as a survivor of crime was most commonly recorded (7350 [9.2%]), but the strength of the association was greatest between emotional or behavioral problems and police contact as a person of interest (unadjusted HR, 4.75; 95% CI, 3.64-6.19). Incidence of police contact as a person of interest was high for children with a pervasive developmental risk profile (unadjusted HR, 13.80; 95% CI, 9.79-19.45).

CONCLUSIONS AND RELEVANCE

This study found an association of emerging emotional or behavioral problems and developmental vulnerabilities with increased risk of police contact for any reason among young children, suggesting that this well-known association in adults and adolescents can be identified at an earlier developmental stage. These findings support primary and secondary interventions to prevent police contact early in life and to target the earliest contacts with the criminal justice and educational systems.

Different needs in patients with schizophrenia spectrum disorders who behave aggressively towards others depend on gender: a latent class analysis approach

BACKGROUND

There is limited research with inconsistent findings on differences between female and male offender patients with a schizophrenia spectrum disorder (SSD), who behave aggressively towards others. This study aimed to analyse inhomogeneities in the dataset and to explore, if gender can account for those.

METHODS

Latent class analysis was used to analyse a mixed forensic dataset consisting of 31 female and 329 male offender patients with SSD, who were accused or convicted of a criminal offence and were admitted to forensic psychiatric inpatient treatment between 1982 and 2016 in Switzerland.

RESULTS

Two homogenous subgroups were identified among SSD symptoms and offence characteristics in forensic SSD patients that can be attributed to gender. Despite an overall less severe criminal and medical history, the female-dominated class was more likely to receive longer prison terms, similarly high antipsychotic dosages, and was less likely to benefit from inpatient treatment. Earlier findings were confirmed and extended in terms of socio-demographic variables, diseases and criminal history, comorbidities (including substance use), the types of offences committed in the past and as index offence, accountability assumed in court, punishment adjudicated, antipsychotic treatment received, and the development of symptoms during psychiatric inpatient treatment.

CONCLUSIONS

Female offender patients with schizophrenia might need a more tailored approach in prevention, assessment and treatment to diminish tendencies of inequity shown in this study.

Associations between individual antipsychotics and the risk of arrests and convictions of violent and other crime: a nationwide within-individual study of 74 925 persons

BACKGROUND

Individuals diagnosed with psychiatric disorders who are prescribed antipsychotics have lower rates of violence and crime but the differential effects of specific antipsychotics are not known. We investigated associations between 10 specific antipsychotic medications and subsequent risks for a range of criminal outcomes.

METHODS

We identified 74 925 individuals who were ever prescribed antipsychotics between 2006 and 2013 using nationwide Swedish registries. We tested for five specific first-generation antipsychotics (levomepromazine, perphenazine, haloperidol, flupentixol, and zuclopenthixol) and five second-generation antipsychotics (clozapine, olanzapine, quetiapine, risperidone, and aripiprazole). The outcomes included violent, drug-related, and any criminal arrests and convictions. We conducted within-individual analyses using fixed-effects Poisson regression models that compared rates of outcomes between periods when each individual was either on or off medication to account for time-stable unmeasured confounders. All models were adjusted for age and concurrent mood stabilizer medications.

RESULTS

The relative risks of all crime outcomes were substantially reduced [range of adjusted rate ratios (aRRs): 0.50-0.67] during periods when the patients were prescribed antipsychotics v. periods when they were not. We found that clozapine (aRRs: 0.28-0.44), olanzapine (aRRs: 0.46-0.72), and risperidone (aRRs: 0.53-0.64) were associated with lower arrest and conviction risks than other antipsychotics, including quetiapine (aRRs: 0.68-0.84) and haloperidol (aRRs: 0.67-0.77). Long-acting injectables as a combined medication class were associated with lower risks of the outcomes but only risperidone was associated with lower risks of all six outcomes (aRRs: 0.33-0.69).

CONCLUSIONS

There is heterogeneity in the associations between specific antipsychotics and subsequent arrests and convictions for any drug-related and violent crimes.

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

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

Childhood Maltreatment, Psychopathology, and Offending Behavior in Patients With Schizophrenia: A Latent Class Analysis Evidencing Disparities in Inpatient Treatment Outcome

Background: Extant research has provided evidence for disparities between patients with schizophrenia spectrum disorder (SSD) who have and have not experienced childhood maltreatment (CM) in terms of treatment outcome, psychopathology and their propensity to engage in offending behavior. However, research addressing all phenomena is scarce. Objective: The current study aims to explore differences between offender patients with SSD and CM and those with SSD and no CM in terms of their offending, psychopathology at different points in time and treatment outcome. Method: In the present explorative study, latent class analysis was used to analyze differences between 197 offender patients with SSD and CM and 173 offender patients with SSD and no CM, who were admitted to forensic psychiatric inpatient treatment between 1982 and 2016 in Switzerland. Results: Three distinct homogenous classes of patients were identified, two of which were probable to have experienced significant CM. One third of patients with SSD and CM were probable to benefit from inpatient treatment, even surpassing results observable in the group without CM, whereas the other group with SSD and CM was probable to benefit less. Patients with SSD and no CM displayed more psychopathology at first diagnosis and prior to their index offense. Interclass differences in offending behavior were minimal. Conclusions: Offender patients with SSD and CM differ not only from offender patients with SSD and no CM, but also amongst themselves. While some with SSD and CM experience a remission in psychopathology and improve their prognosis for future offending behavior, others do not. Directions for future research on SSD and CM are discussed.

Aggressive Behavior and Psychiatric Inpatients: a Narrative Review of the Literature with a Focus on the European Experience

PURPOSE OF REVIEW

We summarized peer-reviewed literature on aggressive episodes perpetrated by adult patients admitted to general hospital units, especially psychiatry or emergency services. We examined the main factors associated with aggressive behaviors in the hospital setting, with a special focus on the European experience.

RECENT FINDINGS

A number of variables, including individual, historical, and contextual variables, are significant risk factors for aggression among hospitalized people. Drug abuse can be considered a trans-dimensional variable which deserves particular attention. Although mental health disorders represent a significant component in the risk of aggression, there are many factors including drug abuse, past history of physically aggressive behavior, childhood abuse, social and cultural patterns, relational factors, and contextual variables that can increase the risk of overt aggressive behavior in the general hospital. This review highlights the need to undertake initiatives aimed to enhance understanding, prevention, and management of violence in general hospital settings across Europe.

Prevalence Rates and Evolution of Psychiatric Disorders Among Incarcerated Youths in Comparison With Non-incarcerated Youths

Background: Our main objective was to provide estimates of the prevalence rates of psychiatric disorders and comorbidities among youths in a juvenile detention center in Geneva, Switzerland. We also aimed to investigate potential positive effects of intensive psychotherapeutic and educational services this center provides. Finally, we examined psychiatric care prior to and after custody as well as the evolution of the youths' mental health during detention. Methods: We conducted a longitudinal study including a group of incarcerated (n = 86) and a group of non-incarcerated (n = 169) youths (12-18 years old). Measures included diagnoses of psychiatric disorders, cognitive functions, trauma, psychopathic traits and the Youth Self-Report (aggressive behavior, attentional disorders, criminal behavior, social withdrawal, anxiety, depression and somatic complaints) collected at baseline and at discharge for the incarcerated group. Data were analyzed using mixed-effect models. Results: Psychiatric disorders were prevalent in the incarcerated group (82.6, 95% CI: 71.6-90.7%), but young people also often suffered from several disorders simultaneously. Two-thirds of the incarcerated participants had a diagnosis of two or more psychiatric disorders. Regarding health care, most incarcerated participants (79.1%) had psychiatric care prior to detention. The planned care after detention was associated with psychiatric comorbidities, care being more likely planned for those with comorbidities (p = 0.030). Compared to the non-incarcerated group, the incarcerated group had lower scores on cognitive functioning (p < 0.001) and higher scores on trauma (p < 0.021) and psychopathic traits (p < 0.034). The youths' stay in the detention center was associated with a positive change of mental health, with externalized problems being significantly reduced at the end of their stay (p = 0.017). Conclusion: Our findings showed that youths in conflict with the law are characterized by (1) their internal vulnerabilities: a high prevalence of psychiatric disorders and psychiatric comorbidities, lower cognitive functions, externalized problems and psychopathic traits; (2) environmental factors: victims of violence and sexual abuse; and (3) their psychiatric history. Besides, the evolution of the most prevalent issues was favorable over time, which puts into question the usual perspective about the deleterious effect of detention.

Court sentences to forensic-psychiatric treatment and imprisonment in Germany: Types of crimes and changes from 1995 to 2009

The management of mentally disordered offenders varies widely across countries. Given the high prevalence of individuals with mental disorders throughout the criminal justice system, it is not always clear why some people receive forensic treatment and others a prison sentence. This project investigated trends in criminal justice sentencing practices in Germany from 1995 to 2009. We analysed officially recorded data taken from 14,100,329 court rulings to describe differences in the index offences committed by individuals sentenced to prison of at least two years and those given a forensic treatment order. The distribution of offence types differed substantially. Forensic patients committed 6.6% of all severe crimes. There was a 50% increase in the number of forensic treatment orders compared to a 11.6% increase in the group of individuals sentenced for crimes of a similar severity. Forensic patients were more likely to have committed a serious offence. This paper provides key epidemiological data and offers a basis for future comparative research. It also concludes that these trends are indicative of a moderate penal policy, without a drift towards penal populism arguably visible in other jurisdictions. Instead, it is argued that the findings are consistent with actuarial social control policies oriented towards risk prediction and crime prevention of high-risk offender groups.

Violent outcomes in first-episode psychosis: A clinical cohort study

AIM

Violence risk is an important part of a comprehensive clinical assessment in first-episode psychosis. This study addresses limitations of previous violent outcome research in first-episode psychosis, which has typically investigated selected cohorts or been restricted to violence occurring prior to service contact, with limited use of police data.

METHODS

For individuals consecutively assessed by Early Intervention in Psychosis (EIP) services in two UK regions (n = 177), violent outcomes in the subsequent 12-months were collected using electronic patient records, supplemented by police data.

RESULTS

Of individuals accepted by EIP services (n = 109), electronic medical records indicated around 1 in 4 (n = 28, 25.7%) perpetrated any physical violence, and 1 in 10 (n = 10, 9.2%) were arrested or charged for violent offences in the 12-months after first contact. Police data on all individuals assessed (n = 177) reported 1 in 7 (n = 26, 14.7%) were arrested or charged for violent offences in the 12-months after first contact.

CONCLUSIONS

EIP services should consider integrating multi-agency sources of data to evaluate violent outcomes. The potential role of violence risk management should be further examined.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Risk of Subjection to Violence and Perpetration of Violence in Persons With Psychiatric Disorders in Sweden

IMPORTANCE

Key outcomes for persons with psychiatric disorders include subjection to violence and perpetration of violence. The occurrence of these outcomes and their associations with psychiatric disorders need to be clarified.

OBJECTIVE

To estimate the associations of a wide range of psychiatric disorders with the risks of subjection to violence and perpetration of violence.

DESIGN, SETTING, AND PARTICIPANTS

A total of 250 419 individuals born between January 1, 1973, and December 31, 1993, were identified to have psychiatric disorders using Swedish nationwide registers. Premorbid subjection to violence was measured since birth. The patients were matched by age and sex to individuals in the general population (n = 2 504 190) and to their full biological siblings without psychiatric disorders (n = 194 788). The start date for the patients and control groups was defined as the discharge date of the first psychiatric episode. The participants were censored either when they migrated, died, experienced the outcome of interest, or reached the end of the study period on December 31, 2013. Data were analyzed from January 15 to September 14, 2019.

EXPOSURES

Patients with common psychiatric disorders (eg, schizophrenia, bipolar disorder, depression, and anxiety) were differentiated using a hierarchical approach. Patients with personality disorders and substance use disorders were also included.

MAIN OUTCOMES AND MEASURES

Subjection to violence was defined as an outpatient visit (excluding a primary care visit), inpatient episode, or death associated with any diagnosis of an injury that was purposefully inflicted by other persons. Perpetration of violence was defined as a violent crime conviction. Stratified Cox regression models were fitted to account for the time at risk, a range of sociodemographic factors, a history of violence, and unmeasured familial confounders (via sibling comparisons).

RESULTS

Among 250 419 patients (55.4% women), the median (interquartile range) age at first diagnosis ranged from 20.0 (17.4-24.0) years for alcohol use disorder to 23.7 (19.9-28.8) years for anxiety disorder. Compared with 2 504 190 matched individuals without psychiatric disorders from the general population, patients with psychiatric disorders were more likely to be subjected to violence (7.1 [95% CI, 6.9-7.2] vs 1.0 [95% CI, 0.9-1.0] per 1000 person-years) and to perpetrate violence (7.5 [95% CI, 7.4-7.6] vs 0.7 [95% CI, 0.7-0.7] per 1000 person-years). In the fully adjusted models, patients with psychiatric disorders were 3 to 4 times more likely than their siblings without psychiatric disorders to be either subjected to violence (adjusted hazard ratio [aHR], 3.4 [95% CI, 3.2-3.6]) or to perpetrate violence (aHR, 4.2 [95% CI, 3.9-4.4]). Diagnosis with any of the specific disorders was associated with higher rates of violent outcomes, with the sole exception of schizophrenia, which was not associated with the risk of subjection to violence.

CONCLUSIONS AND RELEVANCE

In this study, persons with psychiatric disorders were 3 to 4 times more likely than their siblings without psychiatric disorders to have been subjected to violence or to have perpetrated violence after the onset of their conditions. The risks of both outcomes varied by specific psychiatric diagnosis, history of violence, and familial risks. Clinical interventions may benefit from targeted approaches for the assessment and management of risk of violence in people with psychiatric disorders.

Risk of Being Subjected to Crime, Including Violent Crime, After Onset of Mental Illness: A Danish National Registry Study Using Police Data

IMPORTANCE

People with mental illness are more likely to have contact with the criminal justice system, but research to date has focused on risk of offense perpetration, while less is known about risk of being subjected to crime and violence.

OBJECTIVES

To establish the incidence of being subjected to all types of criminal offenses, and by violent crimes separately, after onset of mental illness across the full diagnostic spectrum compared with those in the population without mental illness.

DESIGN, SETTING, AND PARTICIPANTS

This investigation was a longitudinal national cohort study using register data in Denmark. Participants were a cohort of more than 2 million persons born between 1965 and 1998 and followed up from 2001 or from their 15th birthday until December 31, 2013. Analysis was undertaken from November 2016 until February 2018.

EXPOSURES

Cohort members were followed up for onset of mental illness, recorded as first contact with outpatient or inpatient mental health services. Diagnoses across the full spectrum of psychiatric diagnoses were considered separately for men and women.

MAIN OUTCOMES AND MEASURES

Incidence rate ratios (IRRs) were estimated for first subjection to crime event (any crime and violent crime) reported to police after onset of mental illness. The IRRs were adjusted for cohort member's own criminal offending, in addition to several sociodemographic factors.

RESULTS

In a total cohort of 2 058 063 (48.7% male; 51.3% female), the adjusted IRRs for being subjected to crime associated with any mental disorder were 1.49 (95% CI, 1.46-1.51) for men and 1.64 (95% CI, 1.61-1.66) for women. The IRRs were higher for being subjected to violent crime at 1.76 (95% CI, 1.72-1.80) for men and 2.72 (95% CI, 2.65-2.79) for women. The strongest associations were for persons diagnosed as having substance use disorders and personality disorders, but significant risk elevations were found across almost all diagnostic groups examined.

CONCLUSIONS AND RELEVANCE

Onset of mental illness is associated with increased risk of exposure to crime, and violent crime in particular. Elevated risk is not confined to specific diagnostic groups. Women with mental illness are especially vulnerable to being subjected to crime. Individual's own offending accounts for some but not all of the increased vulnerability to being subjected to crime.

Daily stressors as antecedents, correlates, and consequences of alcohol and drug use and cravings in community-based offenders

Justice-involved individuals with alcohol and drug use problems reoffend at higher rates than their nonusing counterparts, with alcohol and drug use serving as an important vector to recidivism. At the daily level, exposure to stressors may exacerbate problematic alcohol and drug use; at the individual level, prior treatment experiences may mitigate substance use as individuals adapt to and learn new coping mechanisms. We conducted a daily diary study using Interactive Voice Response technology over 14 consecutive days with 117 men on probation or parole participating in a community-based treatment program (n = 860 calls) and referred to medication-assisted treatment. Participants reported daily stressors, craving for alcohol and illegal drugs, and use of alcohol and illegal drugs 1 time each day. Results of multilevel models showed significant day-to-day fluctuation in alcohol and drug craving and use. In concurrent models, increases in daily stressors were associated with increases in cravings and use of illegal drugs. Prior treatment experience modified many of these relationships, and additional lagged models revealed that those with less treatment experience reported an increase in next-day alcohol craving when they experienced increases in stressors on the previous day compared to those with more treatment experience. Collectively, these findings highlight the importance of tailoring treatment as a function of individual differences, including prior treatment experiences, and targeting daily stressors and subsequent cravings among justice-involved adults with alcohol and drug use problems. (PsycINFO Database Record