Reports reveal an increase in the number of individuals with serious mental illness in jails, prisons and forensic hospitals. Despite the wide-ranging and devastating consequences of this 'criminalization' of mental illness, there remains a lack of information on the subject as well as on the provision of care for these patients. This important new book fills a gap in the literature by examining topics such as: the history and policy factors related to criminalization; original research on forensic populations; pharmacological and psychological treatment strategies; and principles and guidelines for diversion out of the criminal justice system.
Pharmacological Treatment of Violence in Schizophrenia
Martin T. Strassnig, Vanessa Nascimento, Elizabeth Deckler, and Philip D. Harvey
Most patients with schizophrenia, save for a small minority, are not chronically aggressive or violent.
Known predictors of violence include patients with co-morbid substance use disorders (SUDs) and nonadherence with prescribed treatments, those with co-morbid personality disorders, and those with frequent relapses/arrests/civil commitments.
Among the few modifiable risk factors for violent behavior in patients with schizophrenia is treatment with antipsychotics.
Aside from clozapine, it appears that treatment with long-acting injectable (LAI) medications is superior to oral antipsychotic in terms of violence prevention. Moreover, LAI facilitate the successful implementation of functional skills training in people with schizophrenia. For the high-risk recidivist target population, better life skills have the potential to also reduce risk for contact with the legal system, including an improved ability to live independently in supported environments and interact appropriately with others.
High-risk patients who are resistant to treatment with other antipsychotics should receive treatment with clozapine due to its direct positive effects on impulsive violence, along with a reduction in co-morbid risk factors such as SUDs.
Acute treatment of schizophrenia patients is often triggered by attempting to thwart aggression or violence in an inpatient hospital setting. Administration of oral or injectable antipsychotics to acutely agitated patients, perhaps in conjunction with a benzodiazepine, can lead to rapid de-escalation. Short-acting intramuscular formulations of atypical antipsychotics are now available, perhaps with better tolerability compared to the short-acting intramuscular formulation of haloperidol. New alternative formulations that avoid injections including inhalation and sublingual administration have also become available, further adding to the therapeutic options for calming down acutely agitated patients.1 In contrast, the treatment of chronic aggression and violence can be a more vexing problem in clinical and community settings, including successful transitioning to an outpatient setting and successful residence in the community.2 Most patients with schizophrenia are not chronically aggressive or violent; among patients with schizophrenia, there is a small increase in violence and violent offending on average compared to general population standards in the USA and Europe.3,4 However, much of the excess risk appears to be mediated by substance abuse co-morbidity. Unfortunately, the small subgroup of patients who commit violent acts under certain circumstances are frequently the focus of intense media scrutiny, negatively affecting the public perception of the entire population of schizophrenia patients.5 This contributes to the stigma associated with mental illness, which is considered to be the most significant obstacle to the development of mental health services.6 In fact, patients with psychosis are more likely to be victims rather than perpetrators of violence.7
Aggression and violence are often used interchangeably although in a strict sense, they are two slightly different concepts albeit located along the same continuum: aggression usually involves threatening behavior, whereas violence goes a step further, and adds an act of furtherance, involving physical harm to others. For the purpose of our review, we will include both aggression and violence towards others, while also acknowledging that aggression and violence are multifactorially and dynamically determined. Moreover, there is often a systematic bias in studying violence in schizophrenia, with many samples examining patients who are involuntarily committed to inpatient facilities or who are undomiciled and receive no mental health treatment, while also abusing substances. Because involuntary commitment criteria often require that the patient has already engaged in threatening or otherwise dangerous behaviors, only the patients already likely to commit violent acts or those who have expressed such an intent are being studied in most inpatient samples. Similarly, outpatient studies are often either retrospective studies of violent acts or include only patients civilly committed in outpatient settings, with the same selection bias applicable.
Known predictors of violence include patients with co-morbid substance use disorders (SUDs) and nonadherence with prescribed treatments, those with co-morbid personality disorders, and those with a history of violence, frequent relapses/hospitalizations/arrests/and/or commitments.8 Lifelong antisocial behavior often predated by childhood conduct disorder is a risk factor as well.4 Comprehensive earlier studies from the New York State Mental Health System, and later the California State Hospital System have delineated three types of violence that are common among patients with schizophrenia: psychosis-driven, impulsive (for example, due to fear, anger, provocation), and predatory.9,10 Viewed from a caregiver perspective, the burden of dealing with aggression and violence falls on family members, clinical care staff, roommates, law enforcement, and staffs of emergency rooms and jails, adding a dynamic element that can be either helpful or detrimental, depending on how the interaction is perceived by the aggressor. Effective management of violence thus requires consideration of these risk factors and circumstances as they interact with the type of violence encountered, in addition to pharmacological treatment, as reviewed below.
Because a large proportion of violent patients end up in jail, a variety of jail diversion programs has been implemented in the USA and Europe, among other countries, to reduce their presence in the criminal justice system. Although they vary in their structure and procedures and operate from different juncture points within the criminal justice process, all jail diversion programs have at their core the idea that persons with severe mental illness should be redirected to mental health services rather than the penal system.11 Moreover, linking the mentally ill accused and offenders to community-based treatment services shifts the locus of intervention to community-based mental health treatment, reducing jail time while better serving the mental health needs of these patients. However, patients in these programs do not typically receive court-ordered medications and many of the co-morbidities that are associated with future violence risk (e.g. substance use, antisocial PD, violence history) limit their effectiveness for future violence prevention.