Violence Risk among Youth Referred to a Forensic Mental Health Service

Youth who engage in serious aggressive, violent, or threatening behaviour pose a concern to others about their potential for future acts of violence. The current study investigates violence risk factors among young people referred to a child and youth forensic mental health service. The primary aim of this study is to examine the demographic, historical, and clinical characteristics of a sample of 91 young people in order to assess whether there are distinct groups or clusters that share common profiles. Using a two-step cluster analysis, three distinct clusters were found. Cluster 1 (generally non-violent, n = 34) comprises a subgroup with fewer family adversity factors and an absence of serious violence. Cluster 2 (early violence, n = 35) comprises a subgroup with serious violent histories, comorbid mental health disorders, and an early onset of behavioural difficulties. Cluster 3 (later violence, n = 19) includes young people with serious violent and antisocial histories, and a later onset of behavioural difficulties. The results of the study support the notion that youth referred for specialised violence risk assessments are a heterogeneous group with distinct individual differences. This has implications for determining the level of intervention and treatment required to reduce youth offending and violence.     

Risk of violence among patients in psychiatric treatment: results from a national census

Background: Adverse media coverage of isolated incidents affects the public perception of the risk of violent behavior among people with mental illness. However, the risk of violence is studied most frequently among inpatients, which falsely exaggerates the prevalence of people with mental illness because the majority of individuals receive treatment as outpatients.

Aim: To estimate the prevalence of the risk of violence among inpatients and outpatients in psychiatric treatment, as well as the associations with gender, age, socio-economic status and co-morbid substance use disorders in all major diagnostic categories.

Methods: We conducted a national census of patients in specialist mental health services in Norway, which included 65% of all inpatients (N?=?2,358) and 60% of all outpatients (N?=?23,124).

Results: The prevalence of the risk of violence was 32% among inpatients and 8% among outpatients, where 80% of the patients in specialist mental health services were outpatients. If we weight the prevalence rates accordingly, less than 2% of the patients in specialist mental health services had a high risk of violent behavior.

Conclusions: The stigma attached to those with mental illness is not consistent with the absence or low to modest risk of violent behavior in 98% of the patient group. Substance use disorders must be given priority in the treatment of all patient groups. Mental health care in general and interventions that target violent behavior in particular should address the problems and needs of these patients better, especially those who are unemployed, have a low level of education and have a background of being a refugee or an immigrant.     

First aid actions taken by young people for mental health problems in a close friend or family member: findings from an Australian national survey of youth

This study examined the first aid actions taken by young people to help someone they know and care about who was experiencing a mental health problem and the characteristics of the first aid provider (respondent) and recipient which influence these first aid actions. Participants in a national survey of Australian youth (aged 12-25 years) completed a two-year follow-up phone interview based on one of the following disorders in vignettes: depression, depression with alcohol misuse, social phobia and psychosis. Participants were asked if they knew a family member or close friend who had experienced a similar problem to the vignette character since the initial interview and those who did reported on any actions taken to help the person. Of the 2005 participants interviewed, 609 (30%) reported knowing someone with a similar problem, with depression (with or without alcohol misuse) being the most common problem. Respondent age and gender, recipient gender, and type of mental health problem, all influenced first aid actions. Findings indicate that peers are a major source of support for young people with mental health problems and underscore some important areas and subgroups of young people to target for interventions to improve young people's mental health first aid skills.     

An Exploratory Analysis of Unhealthy and Abusive Relationships for Adults with Serious Mental Illnesses Living in Supportive Housing

Individuals living with serious mental illness are at high risk of chronic homelessness, victimization, and intimate partner violence. In recent years, supportive housing programs have emerged as one way to prevent homelessness and victimization for this population, while also expanding social interactions and social networks. In concert with a focal supportive housing program, this research conducted two focus groups with 18 individuals who have a serious mental illness diagnosis. The authors sought to answer the research question, “What are perceptions of healthy and unhealthy relationships among formerly homeless people with serious mental illness?” To this end, the eight-item questionnaire was created around dimensions of power and control, as well as relationship equality. Findings from an inductive thematic analysis reveal three broad families of themes (relationship ideals, lived experiences, and risk/resources in supportive housing), around which smaller themes and subthemes are organized. Implications for policy, practice, and future research are also discussed.     

Psychiatric impairment,social contact,and violent behavior: evidence from a study of outpatient-committed persons with severe mental disorder

The need to better understand and manage risk of violent behavior among people with severe mental illness in community care settings is increasingly being recognized, as public-sector mental health systems face mandates to provide more cost-effective services in less restrictive environments. The potential for serious violence in a small proportion of severely mentally ill (SMI) individuals has emerged as a key factor that increases cost and limits continuity and normalization of community-based services for populations with psychiatric disabilities. A major challenge to developing better strategies for risk assessment and management in community care settings involves specifying complex interactions between psychiatric impairment and the conditions of social life – including the quality and frequency of contact with others at close quarters. This is a study of the determinants of violent behavior in a sample of 331 adults with severe mental disorders in community-based treatment. An interaction between severity of functional impairment and frequency of social contact was found to be significantly associated with risk of violence. Among respondents with Global Assessment of Functioning (GAF) scores in the lowest 20%, more frequent contact with family and friends was linked to a higher probability of violent events. However, among better functioning respondents, frequent social contact was associated with lower risk of violence and greater satisfaction with relationships. These findings suggest that, where violence risk is concerned, the most salient feature of psychiatric impairment is the impairment of social relationships –the ways in which disorders of thought and mood not only distort one's subjective appraisal of experience and threat, but impair the ability to relate meaningfully to others, to resolve conflict and derive necessary support from family and friends. Thus, social contact may be a mixed blessing for SMI individuals. For some, it signals a positive quality of life, but for others – particularly those with extreme psychiatric impairment – frequent contact may add to conflict, stress, and increased potential and opportunity for physical violence. The impact of psychiatric impairment on violent behavior cannot be known in isolation, but must be considered in a social context. Effective community-based strategies to anticipate and prevent violence in the lives of persons with severe mental illness must take into account such interactions between social and clinical variables.     

Psychosocial function,legal involvement and violence in mental disorder

BackgroundThe correlates of legally significant outcomes that have been identified in people with mental disorders are of limited value in understanding the mechanisms by which these outcomes occur.AimsTo describe the relationships between mental disorder, impaired psychosocial function, and three legally significant outcomes in a representative sample of the US population.MethodsWe used a population survey, the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III, sample size 36,309), to identify people who self-reported serious trouble with the police or the law over the past 12 months and two lifetime outcomes, being incarcerated and engaging in violence to others. DSM-5 categories were generated using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-5. Psychosocial function was assessed using social and role-emotional function scores of the 12-Item Short-Form Health Survey Version 2.ResultsParticipants with mental disorder, but not people with no diagnosis, who reported serious trouble with the police or with the law during the previous 12 months reported significantly worse psychosocial function than those who did not report such trouble. The size of the statistical effect varied by diagnosis, moderate for some forms of mental illness and for alcohol abuse and nonsignificant for drug abuse and the personality disorders. Effect sizes were largest for diagnoses where legally significant outcomes were least common.ConclusionsThe effect of impaired psychosocial function, for instance in disrupting family and social networks that would otherwise protect against these legally significant outcomes, warrants further investigation in studies with longitudinal designs.     

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.     

Complicated Grief,Depression, Health and Attachment Style in First Degree Relatives of Individuals with a Chronic Psychotic Disorders

Complicated grief (CG) is a form of unrelenting grief after the death of a loved one. However, family members of individuals who suffer from Schizophrenia, Schizoaffective disorders and Bipolar disorder may experience symptoms of CG even though their loved one is still alive. The present study assessed CG and risk factors for CG in first degree relatives of individuals with severe chronic mental illness. The incidence of CG was examined in 78 parents, siblings, adult children and spouses recruited through organizations and social media that provide support services for individuals suffering from mental illness and their families. High rates of CG (39.7%) were found in this group. CG was associated with a higher prevalence of posttraumatic and depression symptoms and poorer physical health. These findings may contribute to heightening therapists' awareness of the importance of assessing, acknowledging and resolving CG in the family members of patients with chronic psychotic disorders.

     

The psychiatric epidemiology of violent behaviour

This paper reviews the current state of the debate on the relationship between mental disorder and violent behaviour. Starting from the discussion of methodological approaches to assessing a possible association, the most important studies carried out on the issue in recent years are discussed. Their results concur in supporting the assumption that there is a moderate but reliable association between mental disorder and violence. However, this does not imply that people with mental illness are generally more likely to commit violent acts than members of the general population. An elevated risk of violent behaviour is only evident for specific psychiatric diagnoses and symptom constellations. For schizophrenia and other psychotic disorders, a significant increase in the likelihood to commit violent acts is reported. Substance use disorders and antisocial personality disorder, however, represent a markedly higher risk for violent behaviour. The article further discusses possible determinants of violent behaviour such as psychotic symptoms and comorbidity with substance abuse and considers who is at particular risk of becoming a target of violent acts.     

Fear of crime and related factors in relatives of individuals with mental disorders

This study was conducted to investigate the fear of crime among relatives of individuals with mental disorders. The study was a cross-sectional epidemiological study. The sample consisted of 545 people. A questionnaire to collect data was developed by the researchers using the literature. 11.0% of the women and 19.4% of the men stated that their exposure to crime had decreased. Patients’ relatives felt that the most disturbing behavior of other people towards their relatives was stigmatization (47.3%), while what made patients’ relatives happiest was when other people talked and chatted to the patient (80.3%). The fear of crime in family members of individuals with mental disorders was found to be greater in women. The family members who participated in the study were found to fear their relatives being victims of crime due to stigmatization and social exclusion.     

Effects of Social Networks on Physical Health Among People with Serious Mental Illness

This study examined the effects of social network characteristics on physical health among people with serious mental illness using social transactions that are reciprocal, and the combination of objective and subjective health measures. The sample consisted of a probability sample of 231 adults with serious mental illness who resided in permanent supportive housing in Philadelphia, Pennsylvania. Path analyses were conducted to examine the relationships between social network characteristics and two aspects of medical comorbidity, objective health and subjective health. Bivariate statistics showed that individuals with medical comorbidity were more likely to have contact with their network members and had a higher level of reciprocal positive tangible support when compared to those who did not have medical comorbidity. The results of the path analyses revealed that none of the social network characteristics were associated with better physical health. The lack of a significant relationship between social networks and better physical health is contrary to prior research findings. However, this is the first study to include both types of social transactions simultaneously as predictors of better physical health for individuals with serious mental illness. A longitudinal study would provide more insight into the temporal relationship of social networks and physical health conditions of people with serious mental illness. Furthermore, the transactional nature of social relationships, particularly for those with mental health issues, requires greater exploration.     

Legal Justice and Mental Health

Background. Recovery is a journey not only of personal change but also of social reengagement. It underlines the essence of social environments that are supportive to the recovery of people with ongoing mental health issues. The process of recovery also affects other actors, and likewise these actors exert their influence on the recovery of their family member or friend.

Objective. Since 2009, we have been studying whether the decision-making model called family group conferencing (FGC) helps mental health clients increase their self-reliance. The essence of FGC is that individuals who experience problems have the opportunity to develop a plan together with people from their social network. Clients in mental health have to deal with different forms of disempowerment, especially when they are threatened with compulsory measures. It is an aim to help them regain ownership over their problems as well as over the potential solutions.

Method. From 2011 to 2013, we evaluated 41 family group conferences that were organized for clients in a public mental health care setting in the north of the Netherlands. Each conference was analyzed in a qualitative case study framework.

Results. This article highlights two case portraits. It gives insight into how ownership was restored and what this meant regarding clients’ recovery process.

Conclusion. FGC seems a promising tool to shift the attention from disorders and inabilities to capacities and the rediscovery of social resources.     

Schizophrenia and violence

OBJECTIVE: The relationship between schizophrenia and violence is studied from a psychiatric and a public health perspective. METHOD: All epidemiological studies which have been published since 1990 are reviewed. RESULTS: Despite differences in the methodological approaches chosen the studies reviewed concur in supporting the assumption that there is a moderate but significant association between schizophrenia (or more generally psychotic disorders) and violence. However, compared with the magnitude of risk associated with substance abuse and personality disorders, that associated with schizophrenia or other major mental disorders is small. In addition, the elevated risk to behave violently appears to be limited to particular symptom constellations. The evidence available so far suggests that the proportion of violent crimes committed by people suffering from a severe mental disorder is small. There is no unambiguous evidence of an increase of violent acts committed by severely mentally ill people in general and people suffering from schizophrenia in particular during recent years. Strangers appear to be at an even lower risk of being violently attacked by someone suffering from severe mental disorder than by someone who is mentally healthy. CONCLUSION: While the assessment of relative risk is of great interest for psychiatric researchers who are trying to identify factors which may increase or decrease the risk of violent behaviour among the mentally ill, which in turn may provide some clues as to how to intervene best in order to reduce the risk, the attributable risk is of special interest for the public since it informs about the risk of becoming victim of a violent act committed by someone who is suffering from a mental disorder.     

Effectiveness of a mental health court in reducing criminal recidivism and violence

OBJECTIVE: In response to the large-scale involvement of people with mental disorders in the criminal justice system, many communities have created specialized mental health courts in recent years. However, little research has been done to evaluate the criminal justice outcomes of such courts. This study evaluated whether a mental health court can reduce the risk of recidivism and violence by people with mental disorders who have been arrested. METHOD: A retrospective observational design was used to compare the occurrence of new criminal charges for 170 people who entered a mental health court after arrest and 8,067 other adults with mental disorders who were booked into an urban county jail after arrest during the same interval. A matching strategy based on propensity scores was used to adjust analyses for nonrandom selection into mental health court. RESULTS: Propensity-weighted Cox regression analysis, controlling for other potential confounding variables (demographic characteristics, clinical variables, and criminal history), showed that participation in the mental health court program was associated with longer time without any new criminal charges or new charges for violent crimes. Successful completion of the mental health court program was associated with maintenance of reductions in recidivism and violence after graduates were no longer under supervision of the mental health court. CONCLUSIONS: The results indicate that a mental health court can reduce recidivism and violence by people with mental disorders who are involved in the criminal justice system.     

Social adjustment of adolescents at risk for schizophrenia: the Jerusalem Infant Development Study

OBJECTIVE: To better understand whether poor social adjustment, a core characteristic of schizophrenic illness, may also be an indicator of vulnerability in young people who are at genetic risk for schizophrenia, but who do not have schizophrenia. METHOD: Between 1992 and 1996, 27 Israeli adolescents with a schizophrenic parent, 29 adolescents with no mentally ill parent, and 30 adolescents with a parent having a nonschizophrenic mental disorder were assessed on multiple domains of social adjustment measured using the Social Adjustment Inventory for Children and Adolescents and the Youth Self-Report. RESULTS: Young people with a schizophrenic parent showed poor peer engagement, particularly heterosexual engagement, and social problems characterized by immaturity and unpopularity with peers. These social adjustment difficulties in youths at risk for schizophrenia could not be attributed solely to the presence of early-onset mental disorders, although problems were greater in those with disorders in the schizophrenia spectrum. Young people whose parents had other disorders showed different patterns of social maladjustment characterized by difficult, conflictual relationships with peers and family. CONCLUSION: Adolescents at risk for schizophrenia have social deficits that extend beyond early-onset psychopathology and that may reflect vulnerability to schizophrenic disorder.     

The relationship between patients' gender and violence leading to staff injuries

OBJECTIVE: Although recent research has found similar rates of violence by female and male patients who have serious mental disorders, it is less clear whether violence by female patients is as likely to result in injury as violence by male patients. This study examined the relationship between violent patients' gender and injury to staff members on an inpatient unit. METHODS: All injuries to staff caused by violent behavior by patients on a locked university-based short-term inpatient unit were identified in a search of institutional records from October 1988 to June 1999. We reviewed the medical charts of the 76 patients who injured staff members to compare their demographic and clinical characteristics with those of 314 patients hospitalized during the same period who did not injure staff. RESULTS: Nearly half of the injuries (45 percent) were caused by female patients. Moreover, the proportion of injuries caused by female and male patients was similar to the proportion of females and males in the comparison group. Multivariate logistic regression analysis showed that patients' gender was not associated with injury to staff, even when the analyses controlled for other correlates of violence such as history of violence, violent thought content expressed in the admission mental status examination, and history of noncompliance with medication. CONCLUSIONS: The findings suggest that injuries to staff members on a unit treating both men and women are as likely to be caused by violence by female patients as by male patients. When a female patient exhibits signs of an elevated risk of violence, the significance of that risk should not be discounted on the basis of her gender.     

Development of the Australian neighborhood social fragmentation index and its association with spatial variation in depression across communities

Purpose

We know little about how community structures influence the risk of common mental illnesses. This study presents a new way to establish links between depression and social fragmentation, thereby identifying pathways to better target mental health services and prevention programs to the right people in the right place.

Method

A principal components analysis (PCA) was conducted to develop the proposed Australian neighborhood social fragmentation index (ANSFI). General practice clinical data were used to identify cases of diagnosed depression. The association between ANSFI and depression was explored using multilevel logistic regression. Spatial hot spots (clusters) of depression prevalence and social fragmentation at the statistical area level 1 (SA1) were examined.

Results

Two components of social fragmentation emerged, reflecting fragmentation related to family structure and mobility. Individuals treated for depression in primary care were more likely to live in neighborhoods with lower socioeconomic status and with higher social fragmentation related to family structure. A 1-SD increase in social fragmentation was associated with a 16% higher depression prevalence (95% CI 11%, 20%). However, the association attenuated with adjustment for neighborhood socio-economic status. Considerable spatial variation in social fragmentation and depression patterns across communities was observed.

Conclusions

Developing a social fragmentation index for the first time in Australia at a small area level generates a new line of knowledge on the impact of community structures on health risks. Findings may extend our understanding of the mechanisms that drive geographical variation in the incidence of common mental disorders and mental health care.

     

Sharing suicidal thoughts in social networks: a multi-level perspective of disclosure among people with serious mental illness in India

Promoting disclosure about one’s suicidal thoughts is promising for risk management and recovery; however, almost nothing is known about it in India. In a sample of 25 adults with serious mental illness (Level 2) who nominated 333 social network members (Level 1), we adopted a multilevel perspective to assess patterns and correlates of disclosure. Most people had disclosed (72%; n?=?18) or were intent on doing so (92%; n?=?23). However, only 17% (n?=?58) of network members were identified as prior confidants and 20% (n?=?64) as intended confidants. Multilevel modeling results showed that relational factors and not individual factors were linked to disclosure intent. Network members who were prior confidants, emotionally close, and sources of social support were appealing as future confidants. This highlights the potential utility of network-based safety planning wherein these discerning attributes are used to efficiently recruit would-be confidants for training.     

新疆酒依赖男性患者家庭暴力行为的社会人口学及社会文化学特征研究

目的 探讨新疆酒依赖男性患者家庭暴力行为的社会人口学因素及社会文化学因素,以期为心理干预提供指导.方法 使用自行设计的酒依赖患者家庭暴力调查问卷进行访谈.酒依赖患者均来自新疆精神卫生中心戒酒科及新疆自治区人民医院临床心理科,符合〈中国精神障碍分类与诊断标准（第3版）〉（CCMD-3）中酒依赖诊断标准,均为男性,按其有无家庭施暴史分为施暴组（87例）和无施暴组（84例）.结果 酒依赖男性患者中施暴者民族差异有统计学意义（P＜0.05）,其中汉族酒依赖男性患者施行家庭暴力者比例较高;施暴组年龄、总体收入均低于无施暴组;个体职业者、离婚者明显多于无施暴组（P＜0.05）;两组受教育程度差异无统计学意义（P＞0.05）.施暴组中在成长过程中曾经看见或听见父亲打骂家庭成员或在童年期曾被家庭成员打骂者多于无施暴组（P＜0.05）.结论 酒依赖男性患者施暴组家庭关系不良,收入偏低.在成长经历中接触过暴力史的酒依赖男性患者易实施家庭暴力行为.