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Mental illness, substance use disorder, and violent offending Challenge of dual diagnosis: Current perspectives North West Forensic Academic Network Manchester, U.K., 24 November, 2005. Martin Grann Centre for Violence Prevention Karolinska Institute Stockholm, Sweden Dual diagnosis: The relationship between substance use disorders, mental illness, and violent crime Mental illness ”Dual Diagnosis” A Substance use Violent crime B MENTAL ILLNESS AND VIOLENCE Are the mentally disordered more dangerous than others? (Is the public fear of psychiatric patients warranted?) Mental illness ? Violence A violent act A mental illness A causal link between illness and act of violece Mental illness ? Violence These assumptions are fundamental to... Mens rea, culpability, medico-legal insanity; differentiated sanctions (NGRI, NCRAMD, fitness to plead; ”fängelseförbud” etc) Indeterminate institutionalisations - dangerousness (Dangerous Offenders Act, preventative detention, DSPD, "Särskilda skyddsreaktioner” etc) SUPPORT FOR and AGAINST AN ALLGED ASSOCIATION BETWEEN MENTAL ILLNESS & VIOLENCE (1) • From Plato to Hollywood… • The mythology of the mad serial killer • High-profile cases SUPPORT FOR and AGAINST AN ALLGED ASSOCIATION BETWEEN MENTAL ILLNESS & VIOLENCE (2) Empirical investigations: • Increased prevalence rates of mental disorder amongst prisoners convicted of violent offences • Violence by people with mental disorder • Cohort studies Prevalence of mental disorders in prisoners • Homicide 50-90% mentally disordered, of which 5-20% psychoses (Erb et al 2001; Fazel & Grann 2004; Gottlieb, Gabrielsen & Kramp 1987; Shaw Appleby & Amos 1999) • Prison: One in three prison inmates suffer from serious mental illness (Abrams & Teplin 1991, Blaauw 2002) • Recent meta-analysis suggested 4% psychoses, 12% depression, and 46% antisocial PD in prisons (Fazel & Danesh 2002) • Among defendants referred for forensic evaluation by courts in Sweden: approx. 40% psychosis, concomitant PD 60% and substance use disorder 55% of the cases (Official statistics, RMV) Violence in mentally disordered • Individuals suffering from schizophrenia; higher risk than general population to commit violent offence (Lindqvist & Allebeck 1990, and a large number of others) • Major mental disorder (incl. schz, major depression and bipolar syndrome) 2-6 times higher risk than healthy controls (Brennan 1996; Eronen et al 1996) • 12% of general psychiatric • An association with inpatients commit violent deinstitutionalisation? acts during the first year (Mullen et al 2000; 2004) after discharge (Walsh et al 2001; Monahan et al 2001) Mental Illness ? Violence INTERPRETATION? • ” Weak association, does not warrant current legislations ” • ” A robust association, but accounted for primarily by concomitant substance use and SES factors ” • ” A strong association – and one that is explained by the illness per se, i.e. ’illness drives violence’ ” IS THE GLASS HALF-FULL or HALF-EMPTY? DEBATE Age- and sex-adjusted relative risk of 4 to 6 times higher to offend violently compared with general population Approx. 90% of mentally ill do not offend violently POPULATION IMPACT Population attributable risk (PAR) Population attributable risk fraction (PAF) THE CONTRIBUTION OF MENTAL DISORDER TO VIOLENT CRIME Martin Grann, PhD CPsych, Associate Prof. 1) Honorary Research Fellow 2) Seena Fazel, MB ChB MD MRCPsych, Senior Research Fellow 2) , Research affiliate 1) 1) Karolinska Institute Centre for Violence Prevention Stockholm, Sweden 2) Oxford University Dept. of Psychiatry Oxford, U.K. Population attributable risk DEFINITIONS Individuals: T C CMCM+ M T No of people in the population M No of people hospitalised with psych. diagnosis C No of people convicted of at least one violent crime CM- People without psych hospitalisations who were convicted CM+ People with psych hospitalisations who were convicted DEFINITIONS (contd.) No of violent convictions: T C No of violent convictions of people without psych. admissions NCM+ No of violent convictions of people with psych. admissions CMCM+ M NCM- NC No of violent convictions NC = NCM- + NCM+ DEFINITIONS (contd.) is the rate of violent crimes per 1000 persons in the population r = NC T r0 = NCM- is the rate of violent crimes per 1000 non-disordered persons T-M r1 = NCM+ is the rate of violent crimes per 1000 mentally disordered persons M RR = r1/ r0 RD = r1- r0 RD% = (r1- r0) / r1 is the rate ratio is the rate difference (in rate per 1000) is the rate difference percent (%) DEFINITIONS (contd.) Population attributable risk PAR = r-r0 = NC - NCMT T-M [ ][ ] is the rate of convictions (rate per 1000 offenders) comitted by psychiatric patients Population attributable risk fraction PAF = PAR / r is the % of all convictions in the country comitted by psychiatric patients Note: PAR and PAF estimates assume that there is a causal relationship between mental disorder and crime RESULTS – RAW NUMBERS Individuals 1988-2000: T C CMCM+ M T M = 7 176 361 individuals in population >15 M 441,066 individuals were admitted on at least one occasion for psych. diagnosis C 145,860 individuals were convicted of at least one violent crime CM- 111,191 individuals without psych admission were convicted CM+ 34,635 individuals with psych admission were convicted RESULTS – RAW NUMBERS No of violent crimes 1988-2000: T C 224,126 violent crimes by people without psych. admissions NCM+ 114,330 violent crimes by people with psych. admissions CMCM+ M NCM- NC total 338,456 violent crimes RESULTS r = 45 / 1000 Number of violent crimes per 1000 in the population Population attributable risk PAR = 12 (out of 45) No of violent crimes (per 1000 in the population) committed by people identified as mentally disordered via the inpatient register 1. Patients with severe mental illness (psychoses) 2. Substance use patients 1.) SEVERE MENTAL ILLNESS Psychoses Psychotic disorders, such as schizophrenia, schizoaffective disorder, bipolar disorder - hallucinations - paranoid ideation - isolation, anhedionia - manic conditions - megalomanic ideation - severe depression - catatonic states Severe Mental Illness (SMI) by sex and age-bands (Schizophrenia and other psychoses, N = 98 082, during 1988-2000) Population No. SMI size patients No. crimes Total no. committed No. crimes crimes by SMI committed by r committed patients others Age 15-24 Men Women 561 815 586 683 4 447 3 520 122 946 8 784 3 817 304 119 129 8 480 218.8 15.0 213.7 858.3 14.5 86.4 5.1 0.4 2.3% 2.9% Age 25-39 Men Women 930 121 886 551 12 633 11 107 113 794 7 899 9 109 1 194 104 685 6 705 122.3 8.9 114.1 721.1 7.7 107.5 8.2 1.3 6.7% 14.0% Age 40+ Men Women 1 998 512 26 321 2 212 679 40 054 65 625 5 335 5 605 1 090 60 020 4 245 32.8 2.4 30.4 1.9 213.0 27.2 2.4 0.5 7.3% 19.0% All ages, men All ages, women 3 490 448 43 401 3 685 913 54 681 302 365 22 018 18 531 2 588 283 834 19 430 86.6 6.0 82.3 5.3 427.0 47.3 4.3 0.6 4.9% 10.4% All ages, men and 7 176 361 98 082 women 324 383 21 119 303 264 45.2 42.8 215.3 2.4 5.2% r0 r1 PAR per PAF 1000 Fazel & Grann (in press) American Journal of Psychiatry 2.) SUBSTANCE USE DISORDERS • Alcohol • Drugs such as amphetamine, cocain and heroine • ”Legal drugs used illegally” (benzodiazepines eg Rohypnol) • Poly-drug use Alcohol and Drug Use (N = 144 146) No. No. crimes No. crimes individuals committed committed admitted to by by Principal Diagnosis hospital non-patients patients r r0 r1 PAR PAF Alcohol 105,918 267,558 56,825 48.2 40.4 536.5 7.8 16.2% Drugs 38,228 265,565 58,818 48.2 42.6 1318.0 5.6 17.6% 11.6% Any admission for alcohol or drug use: 23.3% Individual drug classes Opiates 6,167 316,091 8,292 48.2 Cannabis 3,118 318,679 5,704 48.2 Sedatives 5,004 321,676 2,707 48.2 Cocaine 196 323,992 391 48.2 Amphetamine 5,523 313,049 11,334 48.2 Hallucinogens 293 323,921 462 48.2 Solvents 368 323,791 592 48.2 Poly-drug misuse 13,413 303,446 20,937 48.2 Drug-induced psychosis 4,146 315,984 8,399 48.2 47.0 1344.6 1.2 2.5% 47.4 1829.4 0.8 1.7% 47.9 541.0 0.4 0.8% 48.2 1994.9 0.1 0.1% 46.6 2052.1 1.6 3.4% 48.2 1576.8 0.1 0.1% 48.2 1608.7 0.1 0.2% 45.2 1560.9 3.0 6.3% 47.0 2025.8 1.2 2.5% Grann & Fazel (2004) BMJ, 328, 1233-1234. Population-based studies SUMMARY • The contribution of mentally disordered inpatients to violent offending was much higher than expected • Notably, one third of all aggravated assaults, one fourth of all assaults, one fourth of all robberies, and a majority of all homicides were committed by persons who were also psychiatric inpatients at any time during the 13-year study period • However, the contribution to violent crime by people suffering from psychotic illnesses was small, approx 5% • The by far largest population attributable risk was seen in patients hospitalised for substance misuse disorders, who committed 1 in 4 of all violent crimes. CONCLUSION • It makes sense to target the alcohol and drug clients for risk assessment and violence prevention programmes!