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Bad cases, research and reviews The perilous progress of forensic psychiatry. Pamela J Taylor. Bad case? when one person with a mental disorder seriously harms others when such a case stigmatises others with mental disorder when psychiatrists/mh workers are defined by a single case

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Bad cases, research and reviews The perilous progress of forensic psychiatry

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    1. Bad cases, research and reviewsThe perilous progress of forensic psychiatry Pamela J Taylor

    2. Bad case? • when one person with a mental disorder seriously harms others • when such a case stigmatises others with mental disorder • when psychiatrists/mh workers are defined by a single case • when one case alone drives law and policy • Research: • Are you serious? • But there is some – • ** Epidemiology • ** Growth in understanding of mechanisms • ** Outcome studies • ** International perspectives • Reviews: • Clear terms of reference • Take account of accumulated individual cases • Draw on wider evidence, including research • from a multiagency and multidisciplinary perspective • Inform policy, law and practice

    3. ‘Bad cases’ neither new nor local • In UK 1st January 1843 Daniel McNaughton mortally wounded Edward Drummond 19th June 1843 House of Lords: The McNaughton Rules • Occur worldwide

    4. b. 23.11 1963 Dropped out of school; disowned by father Co-workers descn :quiet & unremarkable, but a bit of a loner 1999: schizophrenia After one month in treatment judged "capable of taking care of himself" and released. in and out of hospital 1999. kicked out of several apartments e.g. for throwing his garbage from the balcony 2000 On May 23 2001, again committed to mental hospital, but left after one day; did not return. ‘institutionalized even more often than he had been arrested’ On June 8th 2001, court case pending, took OD, ran amok in a school Wrestled down by staff within minutes; described as being in an extremely confused state when arrested Later, on interrogation he stated: Anything and everything has become unbearable. Time and time again I tried kill myself but I could not do it. I wanted to be arrested and get the death sentence Takuma was hanged barely three years after the attacks Mamoru Takuma

    5. System changes • June 9th 2001 Prime Minister Jun-ichiro Koizuni: The imperfection of the law has become clear and certain changes to Japan’s psychiatric system should be considered for mentally ill offenders • 18th March 2002 ruling Lib-Dems proposed new policy which included establishment of special forensic psychiatry wards in general mental hospitals • July 2003, Diet enacted: Law Concerning Medical Treatment and Observation for People Who Commit Serious Harm to Others Under the Condition of Lost Mind and the Like 2003


    7. Aged 29 High achiever Several years of m. illness 13 voluntary hospitalisations in 2+ years 3,500 pps of casenotes Hospitalised 24.11.1998 Medically discharged 15th December 1998 ‘ought to have an intensive case manager’ disorganised, unable to manage his money, care for himself and becomes non-compliant with meds thought disordered talking to himself very delusional Had attacked at least 13 people including health care staff in the period Bedlam on the Streets Maybe they should have just stenciled it in large letters on AG’s forehead: Ticking time bomb, suffers schizophrenia, if off medication, run for cover! Winerip, 1999 December 26th 1998 had missed 2 OP dates Clinic worker wrote to him that if he hadn’t called by January 6th 1999 his case would be closed January 3rd 1999 pushed Kendra Webdale to her death under a subway train Trial no.1 hung jury Trial no 2. convicted of second degree murder and sentenced to 25years-life Trial no 3. pending, plea bargain guilty as before, 23 years + five years supervision and psychiatric supervision. Andrew Goldstein Kendra Webdale

    8. System changes: Kendra’s Law • November 1999, New York State Assembly and Senate passed The New York Mental Hygiene Law 1999 (MH Law 9.60) The Assisted Outpatient Treatment Program • Mandate for medication, & maybe ‘periodic blood tests/urinalysis, individual or group therapy, day treatment, ed/vocational training, supervision of living arrangements, and any other service’ • No criminal penalty; patient may be removed from community for 72 hours obs if 1. a physician determines; 2. clinical decompensation; compliance not attained • Intended population: mentally ill people who are capable of living in the community with the help of family, friends and mental health professionals, but who, without routine care and treatment, may relapse and become violent or suicidal, or require hospitalization. • Reductions in all three attained, law renewed 20th June 2005 for further five years

    9. A UK Departure • b. 7th June 1960 • In care, temp 1967, perm.1972 • 1st Offence 1972 • All adolescence in care or custody • 1st psychiatric admission 1980 • Mostly in prison 18-32 • 1992 CMHT paranoid personality schizophrenia • 1994 personality disorder • Substance misuse disorders • April 1996 probation order ended • 4th July 1996 CPN concerned • 9th July 1996 Russell attacks • 23rd July admitted to MSU for detox • 12th November 1996 discharged • 23rd January 1997 brief readmission • July 1997 Arrest • 23rd October 1998 first convicted Michael Stone Lin & Megan Russell & Josie Russell

    10. Official responses • Does the Home Secretary believe that further measures will be needed to deal with offenders who are deemed to be extremely violent because of mental illness or personality disorder, but whom psychiatrists diagnose as not likely to respond to treatment? Alan Beith, MP • Yes, I entirely agree with the Right Hon. Gentleman that there must be changes in law and practice in that area. We are urgently considering the matter with my Right hon . Friends in the Department of Health … the psychiatric profession … 20 years ago adopted what I would call a common sense approach … but these days go for a much narrower interpretation of the law. Jack Straw, MP. Hansard 26th October 2000 • The Panel is of the firm view that the policy debate concerning the adequacy of the law, policy and guidance should take place in the context of the actual facts of the case of Michael Stone, as opposed to the incomplete and in some cases inaccurate acounts that have appeared to date. South East Coast Strategic HA, Kent County Council, Kent Probation Area commissioned independent report, 30th November 2000, published October 2006

    11. Criminal Justice Act 2003 Imprisonment for public protection Indefinite sentences for a convicted person considered to be dangerous to the public Usually given a tariff, but must complete courses and show change Government prediction of need: 900 places The reality: 4,800 in July 2008 (33 released) New projection 12,000 by 2014 Higher rates of mental disorder than other prisoners: 1/5 in previous treatment 1/5 on medications The Mental Health Act 2007 Mental disorder means any disorder or disability of mind Promiscuity or other immoral conduct, and sexual deviance no longer excluded Detention if: Suffering from a mental disorder of a nature or degree … Appropriate medical treatment (AMT) is available AMT is that medical treatment which is appropriate the case, taking into account the nature and degree of the mental disorder and all other circumstances of the case New Laws

    12. DSPD • What is it? • A severe disorder of personality • a ‘more likely than not’ risk of offending • a link between the two • Building new services • four high security units 302 places • some medium secure capacity <100 places • Costs • capital cost c.# 330,000 per places • revenue cost c. #250,000 per place per year • Treatment programmes • Research evaluation

    13. b. 18th May 1963 Good school record Mother ill 1980, left UK; d.1985 1986 ‘rambling’; ‘odd behaviour’; first violence; left UK; 1st mh admission 1987 returned to UK; June:schizophrenia July: depression January 1988: ‘drug induced psychosis’ or ‘manipulation for a bed’ 1988-92 many assessments/admissions for schizophrenia and threatening behaviour/violence Saw 43 different psychiatrists in this period 1992 14th August paranoid schizophrenia 10th September: normal mental state, abnormal personality 1st December: SW - ‘nothing untoward in attitude or behaviour’ 10th December: failed outpatient appointment 17th December: killed Jonathan Zito 17th December: FME diagnosed ‘psychotic personality disorder’ 18th December: psychiatrist - ’psychotic unfit for interview’ 22nd December: fp - psychotic needs urgent transfer to hospital But, as elsewhere, most of our single, driving cases are of schizophrenia too Christopher Clunis Jonathan Zito

    14. 1994: Guidance issued by the Department of Health HSG(94)27 Requiring full independent inquiry into a homicide committed by someone previously in contact with mental health services. The Guidance led to nearly 300 independent inquiries up to June 2005 Limitations of the system and challenges to it Munro & Rumgay 2000, BJPsy 40 reports 1988-1997 11 (27.5%) predictable 26 (65%) preventable Constructive outcomes?The Zito Trust & Some knowledge generation

    15. Consecutive series of cases since April 1996 drawn from the [Home Office] Homicide Index Psychiatric reports for court when available (49%) [R v Reid] Previous offending data from the National Crime Operations Faculty Cases submitted to mh services in area of last residence for each case Where service contact identified, questionnaire sent to consultant psychiatrist April 1999-Dec 2003 Total n 2684 Life time history of any mental disorder 806 30% Life time schizophrenia 141 5% Life time contact with mh services 486 18% Contact with services in the last 12 months 249 9% Preventable? 41 21% any diagnosis 23 56% with schizophrenia 7 per year The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness

    16. How bad is the single case effect? • They do tend to be what the wider public knows about our field • Forensic and other psychiatrists can be seduced by the single notorious case, but • a handful of cases have certainly been the catalyst for substantial change in law and sometimes service provision • What is the evidence for effectiveness of the changes? • What impact have such cases had on knowledge generation in the field?

    17. Research in forensic psychiatry/mental health: are you serious? • Recent emergence as a recognised specialty • High growth rate, competing demands and financial disincentives • Small size of the specialty • Effective use of range and differences between relevant disciplines • Special ethical issues • Funding and political factors • Complexity of research models required

    18. Special ethical issues: first steps towards research with prisoners • Application to designated ethics committee: a multi-centre ethics committee (MREC) under the National Health Service (NHS) Central Office for Research Ethics Committees (COREC), which - • requires prior written approval from prison governors • therefore pre-application liaison with prison staff • and ‘sponsorship’ - approval in principle by the university or trust • In practice MREC committee members are unfamiliar with prison research or prisoners • Committee works to time ‘targets’ rather than a process of facilitating ethical research

    19. But success here is only the beginning of the ethics approval process - • Once NHS MREC approval obtained: • Research submission to the Prison Service Planning Group (PSPG) if more than one prison to be involved • NHS research governance permission through the Primary Care Trust (PCT) covering each prison • for fmh: NHS research governance permission from each Mental Health Service Provider Trust (MHT) e.g. for one five site project 11 separate applications: 1xMREC+1xPSPG+5xPCTs+4xMHTs

    20. And what about money?and politics?

    21. Research expenditure per year of potential life lost for selected causes of death Reiss & Roth 1993 $

    22. 40% of all clinical academics NHS funded Annual Department of Health spend on NHS research £680m Other government department annual spend on NHS research £180m Research Councils £440m HE funding Councils paid directly to medical schools £400m 100% forensic mental health clinical academics NHS funded Annual Department of Health spend on fmh research £1.3m Other government department spend on fmh research c. £2m Research Councils negligible No medical School funding for fmh research No dedicated charity A UK funding crisis for forensic mental health research Best Research for Best Health (consultation) Analysis of UK Mental Health Research Funding

    23. An indication of the challenge in setting up good enough research modelsexamples from psychosis and violence

    24. Associations between psychosis and violence are complex and multi-directional • Increased vulnerability to becoming victims of violence * directly: Lehman & Linn ’84, Mueser et al ’98, Walsh et al 2003 * indirectly: 1. neighbourhood of residence Silver 2000, Logdberg, 2004 2. press/public fear/hostility Ward 1997 • Violent victimisation may predispose to psychosis Spauwen et al, 2006; Bebbington et al 2004 • Violent victimisation may predispose to violence e.g. Widom, 1997; Caspi et al, 2002 • Both? Heads et al, 1997 • Increased vulnerabilities once in the criminal justice system, e.g. elevated suicide rate Shaw et al 2003 • More likely to perpetrate violence? - but • More vulnerable to arrest Robertson 1988 • More vulnerable to miscarriage of justice Hilgendorf 1980, Gudjonsson et al 1993, Pearse et al, 1998

    25. Accumulating knowledge Since 1990, sound c.s. epidemiological studies on frequency of violence-mental illness association Some longitudinal data; growing attention to pathway studies Basic understanding of illness mechanisms ‘black box’ outcome studies Management framework studies Gaps Interpersonal studies Subgroup specific studies: * women * specified ethnic minority groups Complex treatment studies Allowance for regional and international differences But, in spite of the difficulties, facts are accumulating and there is greater awareness of real gaps in knowledge

    26. Testing for frequency of association between violence & psychosis: a variety of methods • Psychosis among perpetrators of crime with high clear up rate: homicide • Incidence/prevalence psychosis among criminals • Incidence/prev. crime among those with psychosis • Records linkage by birth cohort 4 European studies; violence 4-7 X general population • Restricted community survey: ECA, USA 4 X • Modified community survey: New York 3X • True community survey: New Zealand: 10X • Trends: Australia records linkage 1975-95 – slight equivalent increase in violence over time patients & public • Population attributable risk 5.2% - health and criminal records linkage - 98,000 patients, 21,119 violent crimes Sweden

    27. Links between alcohol, other drug use and violence with and without mental disorder A cross-sectional US based household surveySwanson et al, 1990 • An Australian records linkage study Wallace et al, 1998 • Schizophrenia and violence: • 7x homicide rate and 2.4x non-fatal violence rate of general population • schizophrenia + substance use: • 29x homicide rate and 19x non-fatal violence rate of general population

    28. Bringing longitudinal data to bear on explanations of associationsArseneault, Caspi, Moffitt, Taylor, Silva, 2000 The cohort: • 93% of all births in Dunedin 01.04.1972-31.03.1973 • 1037 children, 51.6% male • Assessed 3,5,7,9,11,13,15,18,21*. • At 21, 94% survivors recruited – 961 • DIS based diagnoses • Court convictions and self-reported violence

    29. The Dunedin birth cohort: mental disorder and violence at 21 13 31 24 % within group 16 6 8 22 7

    30. Proportion of disorder & violence association independently accounted for by selected explanatory variablesArseneault, Moffitt, Caspi, Taylor, Silva, 2000

    31. Research questions for a high security hospital cohort in England • What diagnoses are associated with comorbid substance use diagnosis? • What are the patterns of substance use in the month prior to a serious index offence? • Case record study of all people resident 1993 with psychosis and/or personality disorder n=1330

    32. Comorbid substance use groups Categorised such that groups are mutually exclusive Cannabis group: 30/36 used cannabis only; 6 also had alcohol use diagnosis Other/mixed drug group: 32/53 diagnosed with multiple drug use disorder; 2 used multiple drugs and alcohol, others single illicit drug use disorders

    33. PD only vs PD + psychosis Alcohol use disorder Χ2=6.47, p <.05 Cannabis use disorder Χ2=44.2, p <.001 Other / mixed drug use disorder Χ2=13.1, p <.001 PD only PD + psychosis

    34. Patterns of substance use in the pathway to the index offence • 77% with alcohol use disorder were using alcohol in the month before the offence • 63% were drinking in the 24 hours before the index offence • In the cannabis group, 64% used drugs in the pre-offence month • 22% were using in the 24 hours before the index offence • Of those with other/mixed drug use disorders, 57% were using drugs in the month prior to the index offence • 34% were using in the 24 hours before the index offence. • Few people without a prior substance use diagnosis misused alcohol or drugs in the period before the index offence: 15% in the month prior, most choosing alcohol 9% in the final 24 hours, again most misusing alcohol

    35. Psychosis and substance use Substance use is significantly less prevalent in those driven to the IO by psychotic symptoms … … perhaps psychosis and substance use provide separate explanations for dangerousness?



    38. So, what about psychotic symptoms?

    39. Delusions A belief - acceptance of proposition without evidence A ‘normal delusion’: belief held to be false because held by a political, cultural or religious opponent A ‘psychotic delusion’: Absolute conviction of the truth of a proposition which is idiosyncratic, incorrigible, ego-involved and often preoccupying’ Kraupl Taylor, 1979 Standardised schedules Bell et al, 2006 Threat/control-override symptoms Feeling that one’s mind is dominated by forces beyond one’s control Feeling that thoughts are being put into one’s mind that are not one’s own Feeling that there are people who wish to do one harm From Psychiatric Epidemiologic Research Interview Dohrenwend et el, 1980 Delusions and threat/control-override symptoms

    40. Studies associating delusions with violence • Taylor, 1985, especially serious violence; pre-trial prisoners, UK • Robertson and Taylor, 1993, pre-trial prisoners, UK • Taylor et al, 1998, almost all serous violence, high security hospital patients, UK • Appelbaum et al, 2000, mostly minor/moderate violence, general psychiatric patients, USA • Teasdale et al, 2006, as Appelbaum sample, confirmed association with threat delusions for men, not women • Swanson et al, 2006, USA-wide sample general psychiatric patients, association with more serious violence

    41. Studies associating TCO symptoms with violence • Link and Steuve, 1994, USA general psychiatric patients and community controls in New York • Swanson et al, 1996, 3-centre USA study general psychiatric patients • Link et al, 1998 Israeli population based sample • Bjørkly & Havik, 2003, small Norwegian sample seriously mentally ill and violent patients • Stompe et al, 2004, Austrian NGRI men – more serious violence • Hodgins et al, 2003, forensic and general psychiatry discharged men, Canada, Germany, Finland & Sweden; longitudinal study; at least one TCO

    42. Does social context make a difference?

    43. Why be concerned about social context? relationship of perpetrator to victim & seriousness of index offence (n=975) Johnston & Taylor, 2003

    44. OTHER EVIDENCE FOR INTER-RELATIONSHIP BETWEEN DELUSIONAL DRIVE, SERIOUSNESS OF VIOLENCE AND SOCIAL NETWORKS • Among UK psychotic male offenders those driven to offend by their delusions, more serious violence and social networks more intact than those not delusionally driven Taylor, 1993 • Among all first forensic evaluation violent offenders with schizophrenia in Sweden 1992-2000, injuries to family members more serious than injuries to others Nordström & Kullgren, 2003 • Among all Swedish schizophrenic homicides 1992-2000, those killing family members more likely to have been delusionally driven Nordström et al, 2006

    45. Do people with delusions talk to others about their principal belief?(n=58) 43% 17%

    46. Whoever they talk to about their delusions – probably not the psychiatristsMcCabe et al, 2002 • Qualitative study of 32 patients and 7 psychiatrists • Patients actively tried to talk about the content of their delusions and other psychotic symptoms • The psychiatrists responded with hesitation, a question, a smile or a laugh; if relatives/lay carers present, the psychiatrists then asked the carer a question • Mean length per interview of specific talk about psychotic symptoms: 67 seconds

    47. But, maybe that’s just as well!

    48. Problem: any concern that delusions change in relation to talking about them depends on giving up a belief about these beliefs • A delusion: any false judgement held with 1.’extraordinary conviction’ 2. ‘imperviousness to other experiences and to compelling counter-argument’ 3. ‘their content is impossible’. Jaspers, 1913 • A delusion has 7 defining characteristics, including ‘… unresponsive to the presentation of evidence contrary to the belief’ Oltmanns, 1988 • A delusion is a fixed, false belief, held with absolute conviction and not amenable to reason (DSM-IV) APA, 1997

    49. Beliefs and delusions: steps towards a dimensional view • Successful out-patient psychotherapy of a chronic schizophrenic with a delusion based on borrowed guilt Beck, 1952 • Hallucinations and delusions as points on continua Rating scale evidence. Strauss, 1969 • A multi-dimensional view of delusions. Kendler et al, 1983 • Techniques for measuring psychological change. Shapiro, 1961 • A longitudinal perspective. Hole et al,1979; Brett-Jones et al, 1987. • US McArthur study group: up to 1/3 people had changes in delusions over each 10 week interval Appelbaum et al, 2004