The Role of Substance Abuse in Psychotic Versus Personality Disordered Offenders Detained Under the Dutch Entrustment Act (TBS): An Exploratory Study

Mentally disordered patients that abuse drugs or alcohol have a larger number of criminal convictions. Early starters who had their first conviction before the age of 18, especially, more often have a diagnosis of substance abuse and are more often intoxicated at the time of the offense compared to late starters. The present study involved four groups of Dutch patients (n = 137): three groups of violent offenders (psychotic and personality disordered patients) and one group of non-delinquent psychotic patients from general psychiatry. All data were retrieved retrospectively. The results showed that early starters were intoxicated more often, started with substance abuse at an earlier age and more often had a diagnosis of substance abuse at the time of the index offense than late starters. Personality disordered offenders were intoxicated more often and more often had a prior diagnosis of substance abuse at the time of the offense than psychotic offenders. To a limited extent, psychotic offenders with a diagnosis of a substance-related disorder or intoxication at the time of the offense had a more extensive criminal history than personality disordered offenders. Substance abuse has an aggravating effect on criminogenic behavior, depending on the age at first conviction and diagnosis.     

An outpatient psychiatry program for offenders with mental disorders found not guilty by reason of insanity

OBJECTIVE: Rehospitalization and criminal recidivism were examined among a group of offenders with mental disorders adjudicated as not guilty by reason of insanity and mandated to receive treatment in a forensic psychiatric outpatient program as a condition of release. METHODS: A retrospective chart review was conducted for 43 offenders with mental disorders who were acquitted as being not guilty by reason of insanity for the index offense and were active in the outpatient treatment program in 1996. Data were abstracted on sociodemographic, psychiatric, and criminal characteristics predating the index offense; rehospitalizations and new crimes and rearrests after the offense; and clinical and psychosocial functional outcomes after enrollment in the outpatient program. RESULTS: For the 43 patients, the mean length of stay in the program was 68 months, with a range of 4.9 months to 18.4 years. Almost two-thirds of the patients were diagnosed as having schizophrenia, schizoaffective disorder, or a nonaffective psychotic disorder; 58 percent had a comorbid substance use disorder, and 63 percent had an axis II diagnosis. Since program enrollment, 20 patients (47 percent) were rehospitalized at least once, and eight (19 percent) were rearrested or had committed a new crime. At the end of 1996, only nine (24 percent) were in full remission, and 26 (68 percent) showed at least one indicator of difficulty reintegrating into the community. CONCLUSIONS: Even after treatment in a specialized forensic program, this sample of offenders with serious mental disorders remained impaired symptomatically and functionally. Although avoidance of rehospitalization is considered a successful outcome, rehospitalization is preferable to rearrest for this forensic population.     

Treatment prospects for persons with severe mental illness in an urban county jail

OBJECTIVE: A retrospective study of inmates with severe mental illness in a large, urban county jail aimed to obtain information about their psychiatric and criminal histories and status, the psychiatric services they used while incarcerated, and the challenges they might present in psychiatric treatment after release. METHODS: The authors ascertained demographic characteristics, diagnoses, psychiatric and legal histories, and current psychiatric condition and treatment from jail psychiatric records of a random sample of 104 male inmates with mental illness and from electronic county mental health records and state records of criminal histories. RESULTS: Seventy-eight inmates (75%) were diagnosed as having a severe mental illness. Of these, 59 (76%) required inpatient care or its equivalent for part of their time in jail for the current offense. Of the inmates with severe mental illness, 92% had a history of nonadherence to medications before this arrest, 95% had prior arrests, 72% had prior arrests for violent crimes against persons, and 76% were known to have a history of substance abuse. CONCLUSIONS: A large percentage of persons with severe mental illness received their acute psychiatric inpatient treatment in the criminal justice system rather than in the mental health system. The persons with severe mental illness in this study would present a major challenge in treatment in any setting given their psychiatric and criminal histories. The resources of the mental health system need to be greatly expanded, with priority given to treating persons who are criminalized or who are in danger of becoming criminalized.     

Police-registered offenses and psychiatric disorders among young males

OBJECTIVE: To study associations between crime and psychiatric disorders among adolescent males in a representative population-based cohort study. METHOD: The sample includes 2,712 Finnish boys born in 1981. Information on criminality consists of offenses registered in the Finnish National Police Register 1998-2001. Crime was classified according to frequency and type (drug, violent, property, traffic, and drunk driving offenses). Information on psychiatric diagnoses between 1999 and 2004 was collected from the Finnish National Military Register. RESULTS: Of the 2,712 boys, 22% had a crime registration during the 4-year period, and 10% had at least one psychiatric disorder according to the Military Register. Those with psychiatric disorders accounted for 49% of all crimes. Of those with more than five crimes (n = 98), 59% had psychiatric diagnoses. After adjusting for other crime types and childhood socio-economic status, property crime was independently associated with several diagnoses: antisocial personality (APD), substance use (SUD), psychotic, anxiety, and adjustment disorders. Drug offending was independently associated with APD, SUD, and psychotic disorder, and traffic offenses with APD. CONCLUSIONS: Youth crime is predominantly associated with antisocial personality and substance use disorders. Crime prevention efforts should focus on boys showing a risk for antisocial and substance use problems. In particular, property, drug, and repeat offenders need mental health and substance use assessment. There is a need to develop integrated mental health and substance use treatment services for young offenders within or alongside the criminal justice system.     

Schizophrenia and major affective disorder: forensic psychiatric issues

A group of schizophrenic (S) and major affective disorder (MAD) patients assessed in a Forensic Psychiatric Department was studied in depth to test the hypothesis that these patients commit crimes during periods of serious psychiatric disturbance, even if other sociodemographic factors might be contributing to their criminal behavior. The demographic, psychiatric, psychological and legal data were analyzed. The schizophrenic group was overrepresented in this sample compared with the hospitalization pattern for S and MAD patients as a whole. Both groups showed demographic characteristics such as mean age, marital and family status and education and employment, consistent with the diagnoses. S offenders tended to be either chronically ill or paranoid type and MAD offenders the early onset, bipolar type. Both groups showed evidence of serious psychiatric disturbance at the time of assessment and at the time of the alleged offense. S offenders were considered more dangerous based on clinical criteria and showed an increased tendency to assault. About two-thirds of the total group were considered unfit to stand trial at the time of assessment and about three-quarters were considered not fully responsible for the alleged offense from psychiatric viewpoint. These findings confirm the hypothesis that criminal behavior in these seriously ill patients is at least partly due to the psychiatric disturbance itself. The need for psychiatric assessment and treatment of these mentally ill offenders is thus clearly shown.     

Intended effects and actual outcome of the Forensic Mental Care Act of 1992: a study of 367 cases of forensic psychiatric investigation in Sweden

The legislation regulating sanctions for offenders with mental disorders has been under parliamentary review in Sweden, and major changes have been discussed. In the present study, we have explored the expectations and effects of the previous change in legislation, introduced in 1992 and aimed at reducing coercive psychiatric treatment. Two cohorts of male subjects, admitted for forensic psychiatric investigation before (1988-90, n = 187) and after (1993-95, n = 180) 1992, were compared regarding sanctions, diagnoses and background data with a possible impact on the study populations. Contrary to expectations, the 1993-95 cohort was characterized by increased proportions of psychotic disorders and sentences to forensic psychiatric treatment. In both cohorts, few cases had an adequate outpatient treatment. A tendency to shorter compulsory inpatient treatment periods during the last year before the index crimes was found for those with psychotic disorders in the 1993-95 cohort. The frequency of immigrants with psychotic disorders was markedly increased in the later cohort. The intention of the new legislation to minimize forensic psychiatric treatment was thus counteracted by an unexpected increase in number of offenders with psychotic disorders. To what extent these findings are ascribable to factors other than the new legislation, such as reduced inpatient treatment facilities and generally decreased economic growth rate that coincided with the observation period, cannot be estimated in a limited study population such as ours.     

Commentary: sex offenders and insanity

Sex offenders with a psychotic illness present challenges in the determination of criminal responsibility, risk assessment, and psychiatric treatment. Novak et al. present data that raise concerns regarding how forensic psychiatrists could conclude sex offenders were not responsible for their offenses in the absence of clear evidence of psychotic symptoms at the time of assessment and/or offense. They also highlight issues of risk assessment and management of psychotic sex offenders that have not been adequately studied. We require further research of psychotic sex offenders to be able to offer scientifically supported opinions on risk assessment to courts and decision-makers.     

Homicide of Strangers by People with a Psychotic Illness

Background: The homicide of strangers by people with psychosis, referred to here as “stranger homicides,” are rare and tragic events that generate adverse publicity for mental health services and have resulted in significant changes in mental health policy and law. Aim: To estimate the incidence of stranger homicides, using data from previously published studies, and to compare the characteristics of psychotic offenders who killed strangers with the characteristics of those who killed a close relative. Method: Meta-analysis of the population-based studies of homicide by persons suffering from a psychosis in which the number of subjects who killed strangers was also reported. Characteristics of stranger homicide and family homicide offenders were examined in a multicenter case–control study of homicide during psychotic illness in four high-income countries. Results: A pooled estimate of 1 stranger homicide per 14.3 million people per year (95% confidence interval, 1 in 18.9 million to 1 in 11.5 million people per year) was calculated by meta-analysis of 7 studies. The characteristics of the 42 stranger homicide offenders from New South Wales [NSW], Quebec and Eastern Ontario, Finland, and the Netherlands were identified. Twenty seven (64%) of these had never previously received treatment with antipsychotic medication. The stranger homicide offenders were more likely to be homeless, have exhibited antisocial conduct, and had fewer negative symptoms than those who killed family members. The victims of stranger homicide were mostly adult males and the homicides rarely occurred in the victim’s home or workplace. Conclusions: Stranger homicide in psychosis is extremely rare and is even rarer for a patient who has received treatment with antipsychotic medication. A lack of distinguishing characteristics of stranger homicide offenders and an extremely low base rate of stranger-homicide suggests that risk assessment of patients known to have a psychotic illness will be of little assistance in the prevention of stranger homicides.     

Intended effects and actual outcome of the Forensic Mental Care Act of 1992: A study of 367 cases of forensic psychiatric investigation in Sweden

The legislation regulating sanctions for offenders with mental disorders has been under parliamentary review in Sweden, and major changes have been discussed. In the present study, we have explored the expectations and effects of the previous change in legislation, introduced in 1992 and aimed at reducing coercive psychiatric treatment. Two cohorts of male subjects, admitted for forensic psychiatric investigation before (1988–90, n=187) and after (1993–95, n=180) 1992, were compared regarding sanctions, diagnoses and background data with a possible impact on the study populations. Contrary to expectations, the 1993–95 cohort was characterized by increased proportions of psychotic disorders and sentences to forensic psychiatric treatment. In both cohorts, few cases had an adequate outpatient treatment. A tendency to shorter compulsory inpatient treatment periods during the last year before the index crimes was found for those with psychotic disorders in the 1993–95 cohort. The frequency of immigrants with psychotic disorders was markedly increased in the later cohort. The intention of the new legislation to minimize forensic psychiatric treatment was thus counteracted by an unexpected increase in number of offenders with psychotic disorders. To what extent these findings are ascribable to factors other than the new legislation, such as reduced inpatient treatment facilities and generally decreased economic growth rate that coincided with the observation period, cannot be estimated in a limited study population such as ours.     

Psychiatric morbidity among homicide offenders: a Swedish population study

OBJECTIVE: The authors examined psychiatric diagnoses of all individuals convicted of homicide and attempted homicide in Sweden from 1988 to 2001 (N=2,005). METHOD: High-quality national crime and hospital registers were linked to investigate standardized psychiatric diagnoses of homicide offenders. RESULTS: The presence or absence of psychiatric diagnoses was ascertained for 1,625 (81%) of the homicide offenders; 1,464 (90%) of these offenders had a psychiatric diagnosis. Twenty percent (N=409) of all 2,005 offenders had a psychotic illness, and 54% (N=589) of a subgroup of 1,091 offenders with information on secondary diagnoses had a personality disorder as a principal or secondary diagnosis. Only 10% of the offenders for whom psychiatric diagnostic information was available had no diagnosis. CONCLUSIONS: Using a comprehensive method for identifying psychiatric illness in homicide offenders, the authors found higher rates of psychiatric morbidity than previous studies. Their findings underline the importance of psychiatric assessment in homicide offenders and suggest that treatment might have a preventive role.     

Psychiatric aspects of homicide

Homicide is frequently associated with mental illness and suicide. The present study is an investigation of all known homicide incidents in Iceland during the past 80 years (1900–1979). There were 45 homicide incidents, involving 52 victims and 47 offenders. One-third of the perpetrators were either psychotic, mentally subnormal, or committed suicide. A further one-third were diagnosed as personality disordered, alcoholic, drug dependent or neurotic. A substantial proportion of the offenders suffered from fairly marked physical disabilities, and the mentally ill were significantly more frequently afflicted by such defects. Over 60 % of the offenders and 50 % of the victims were under the influence of alcohol at the material time. The findings are generally consistent with those of previous psychiatric studies of homicide.     

Paternal filicide in Québec

In this retrospective study, relevant demographic, social, and clinical variables were examined in 77 cases of paternal filicide. Between 1991 and 2001, all consecutive coroners' files on domestic homicide in Québec, Canada, were reviewed, and 77 child victims of 60 male parent perpetrators were identified. The results support data indicating that more fathers commit filicide than do mothers. A history of family abuse was characteristic of a substantial number of cases, and most of the cases involved violent means of homicide. Filicide was frequently (60%) followed by the suicide of the perpetrator and more so (86%) in cases involving multiple sibling victims. The abuse of drugs and alcohol was rare. At the time of the offense, most of the perpetrators were suffering from a psychiatric illness, usually depressive disorder. Nearly one-third were in a psychotic state. The proportion of fatal abuse cases was comparatively low. Many of the perpetrators had had contact with health professionals prior to the offense, although none had received treatment for a psychiatric illness.     

精神病患者控制障碍作案特点的分析

目的 探讨精神病患者控制障碍作案的特点。方法 采用回顾性研究的方法,对１２１例精神病患者（研究组）控制障碍作案及１１５例精神正常人（对照组）作案的特点进行分析和比较。结果 研究组以故意伤害和故意杀人为主（７４．４％）,抢劫案比例（５．０％）低于对照组（１３．０％;Ｐ〈０。０５）;冲动作案较多（５３。７％）,心理危机作案为其所特有（７．４％,对照组为０）,生物性动机的比例（３５。５％）高,常缺乏反动     

Victim relations and victim gender in violent crimes committed by offenders with schizophrenia

BACKGROUND: Family members and friends appear to be most at risk of becoming victims of violence committed by offenders with major mental disorders. The aim of the present study is to examine, in a national sample, victim relation in violent crimes committed by male offenders with schizophrenia, with special reference to victim gender and the severity of violence. METHOD: We identified all violent offenders who were diagnosed with schizophrenia in forensic psychiatric evaluations during the years 1992-2000 and examined their court convictions. In total 588 victims were included, 327 men and 261 women, and distributed into three groups based on their relation to the offender: Family of origin (n = 77), Network (n = 183) and Unacquainted (n = 328). RESULTS: The majority of the victims were unacquainted with the offender, but the violence was less severe in this group. Among family members, e. g. parents, siblings and grandparents, there were more female than male victims (60 % vs 40 %), and victims in families, as well as males within the offender's network, were those most likely to be seriously or fatally injured. Female family victims, in particular mothers, were those most likely to die as victims of severe violence. CONCLUSIONS: The study highlights the risk for family members and the immediate network of becoming a target of violence. Mental health services together with community-based services have an important task in identifying risk situations and taking preventive measures.     

Is there a case for a specialist forensic psychiatry service for the elderly?

BACKGROUND: The number of elderly offenders in England and Wales is increasing. There is, therefore, a concern that their needs may not be met by existing forensic services. However, there is a paucity of information on elderly patients referred to existing forensic psychiatric units. METHOD: Data on patients over the age of 65 years referred to a large medium secure forensic psychiatric unit in London were collected for a 13-year period using a retrospective design. The sample was divided into those who had first offended before the age of 65 and those who had offended after the age of 65. Data was also collected on victims of the offences. RESULTS: 5477 referrals were made during the study period. Those aged over 65 years accounted for 78 (1.4%) of all referrals. These 78 referrals were for 55 patients. Forty-five of these had offended. Case notes of 42 patients from this group were screened. Sexual and violent offences accounted respectively for 20 (47%) and 15 (36%) of offences. 31% had no psychiatric disorder but organic disorders accounted for 21% of cases. Only eight (19%) required admission to the medium secure unit. Fourteen (33%) had first offended after the age of 65 while others were known to either the forensic services or criminal justice system before the age of 65. The two groups did not differ from each other. CONCLUSIONS: The elderly accounted for very few referrals to the medium secure forensic service, yet there is a high prevalence of psychiatric morbidity in both remand and sentenced elderly prisoners. Therefore, elderly offenders with psychiatric morbidity may benefit from specialist old age psychiatric forensic services, perhaps at a supraregional level.     

Psychotic disorders among homeless subjects attending a psychiatric emergency service

Background Homelessness is an increas- ing problem among subjects with severe mental illnesses and little is known about the characteristics of homeless subjects with psychosis using emergency psychiatric services. The aims of the present study were to assess the frequency of psychotic disorders among subjects attending a psychiatric emergency service and to explore the clinical and demographic characteristics of these subjects and the management proposed by the emergency staff. Methods All homeless patients (n = 104) consecutively attending a psychiatric emergency service were included over a 6-month period. Patients were categorised according to ICD-10 diagnoses as presenting with psychotic disorder (schizophrenia and other non-affective psychotic disorders) versus other disorders. A random sample of matched non-homeless controls (n = 71) was included over the same period. Results Nearly one out of three homeless subjects (32.7%) presented with a psychotic disorder, a higher proportion than that found in non-homeless subjects (15.7%). Compared to non-homeless subjects with psychosis, homeless subjects with psychosis were more likely to be male and to present with drug use disorder. The likelihood of being hospitalised after attending the psychiatric emergency services did not significantly differ between the two groups. Compared to homeless subjects with other psychiatric disorders, homeless subjects with psychosis were more likely to be single, to have a history of psychiatric hospitalisation and presented less frequently with anxiety or depressive symptoms motivating admission. Conclusion Most homeless subjects with psychosis attending a psychiatric emergency service were already identified as suffering from a severe mental illness, suggesting that homelessness was a consequence of a break in contact with mental health services. Since homelessness is incompatible with the adequate management of psychosis, strategies have to be developed in mental health organisations in combination with outside partnerships, to drastically reduce the frequency of this condition in subjects with psychosis.     

Crime among homeless military veterans who abuse substances

This was a study of crime among 188 homeless persons who were in a Veterans' Affairs Medical Center program for substance abusers. The purpose of the study was to find out: (a) what proportion committed crimes, and (b) what other problems, relational factors, and personal attributes predict crime. Data indicate 27% of these homeless veterans committed nuisance offenses, and 41% have committed crimes in the past year. Logistic regression procedures indicated that alcohol and other drug abuse, less education, lack of employment, psychiatric problems, and living with a substance abuser increased the odds of committing crimes. This study also finds that physical and sexual abuse before 18 years of age increases the odds of committing crimes, whereas self-efficacy, ego integrity, and resilience decrease these odds. These latter factors have received scant attention in the literature on homeless substance abusers, and yet they are among the strongest predictors of crime. Implications for psychiatric rehabilitation are discussed.     

Sex offenders and insanity: an examination of 42 individuals found not guilty by reason of insanity

Although currently there is a large body of research on the characteristics and treatment of sex offenders, very little research has been conducted to investigate the characteristics of sex offenders who have been adjudicated insane. This study included 42 patients at Napa State Hospital who were adjudicated not guilty by reason of insanity (NGRI) for a sex offense. The sample was further divided into offenders whose victims were children and those whose victims were adults. Data were collected with a structured chart review instrument. A large percentage of the sex offenders received a primary diagnosis of schizophrenia or schizoaffective disorder, and many had a comorbid substance use disorder. The high percentage of sex offenders in the current study with diagnosed schizophrenia or schizoaffective disorder may represent a previously unstudied subgroup of sex offenders. An alternative explanation is that the experts did not evaluate substance use and intoxication adequately, assess for malingering, or apply the proper legal standard for insanity.     

Urgent psychiatric transfers from prison in England and Wales: a prison perspective

Prisoners on remand are at high risk of mental illness. They have a high rate of suicide and a high incidence of psychotic illness. Provision does exist within the Mental Health Act (1983) for the emergency transfer of remanded prisoners by transfer order (section 48), but this facility is used to varying degrees throughout England and Wales. This is a retrospective case study of all patients transferred from Belrnarsh Prison under this emergency provision (S48) between April 1991 and March 1992. Twenty-two transfers were enacted (two patients on two separate occasions) during the trial period. Of these 22, 15 (68%) had a paranoid psychotic illness; 14/20 (70%) had committed serious violent offences; 14/22 (63%) were transferred to locked wards of general psychiatric hospitals; 5 (22%) went to regional secure units; 3 (14%) went to maximum secure hospitals. Rapid transfer to psychiatric hospital for all those offenders who are seriously psychiatrically ill is one of the main recommendations of a recent Department of Health/Home Office Report (Department of Health/Home Office, 1991). The existing provisions are shown to be an effective means to enact such emergency transfers. Many such transfers can be managed in the general psychiatric service.     

Mentally disordered offenders. Patterns in the relationship between mental disorder and crime.

Five patterns among mentally disordered offenders are distinguished by the relationship between mental disorder, on the one hand, and criminality, on the other. Pattern 1 offenders are those for whom crime is a response to psychotic symptoms, most often delusions or hallucinations. Pattern 2 offenders commit crimes motivated by compulsive desires, such as sex offenses by paraphiles and offenses regarded as evidence of disorders of impulse control. Pattern 3 offenders are those with personality disorder for whom the crime is merely one example of a maladaptive pattern of voluntary and knowing behavior. Pattern 4 offenders have coincidental mental illness that is unrelated to the crime. Pattern 5 offenders are those who become mentally disordered or feign mental disorder as a result of their crimes, such as those who dissociate upon seeing what they have done, those who become depressed in prison, those who become psychotic on death row, and those who malinger mental illness. Although these categories do not determine whether offenders are responsible for their behavior, some unknown proportion of Pattern 1 offenders do meet legal criteria for insanity, depending on the facts of each case and the applicable legal standards. It is arguable whether or not Pattern 2 offenders ever meet legal criteria of insanity. Offenders evidencing only Patterns 3, 4, or 5 are not candidates for an insanity defense.