Mental illness, substance use disorder,Mental illness, substance use disorder,and violent offendingand violent offending

Challenge of dual diagnosis: Current perspectivesChallenge of dual diagnosis: Current perspectives

North West Forensic Academic NetworkNorth West Forensic Academic NetworkManchester, U.K., 24 November, 2005.Manchester, U.K., 24 November, 2005.

Martin Grann

Centre for Violence PreventionKarolinska InstituteStockholm, Sweden

Mental illnessMental illness

Substance useSubstance use Violent crimeViolent crime

”Dual Diagnosis” A

B

Dual diagnosis: The relationship between substanceDual diagnosis: The relationship between substanceuse disorders, mental illness, and violent crimeuse disorders, mental illness, and violent crime

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 actA violent act

A mental illnessA mental illness

A causal link between illness and act of violeceA causal link between illness and act of violece

Mental illness Violence

?

These assumptions are fundamental to...These assumptions are fundamental to... Mens reaMens rea, culpability, medico-legal insanity; , culpability, medico-legal insanity; differentiated sanctionsdifferentiated sanctions(NGRI, NCRAMD, fitness to plead; ”fängelseförbud” etc)(NGRI, NCRAMD, fitness to plead; ”fängelseförbud” etc)

Indeterminate institutionalisations - dangerousnessIndeterminate institutionalisations - dangerousness(Dangerous Offenders Act, preventative detention, DSPD, "Särskilda (Dangerous Offenders Act, preventative detention, DSPD, "Särskilda skyddsreaktioner” etc)skyddsreaktioner” etc)

SUPPORT FOR and AGAINSTSUPPORT FOR and AGAINSTAN ALLGED ASSOCIATION BETWEENAN ALLGED ASSOCIATION BETWEEN

MENTAL ILLNESS & VIOLENCE (1)MENTAL ILLNESS & VIOLENCE (1)

• From Plato to Hollywood…• The mythology of the mad serial killer• High-profile cases

SUPPORT FOR and AGAINSTSUPPORT FOR and AGAINSTAN ALLGED ASSOCIATION BETWEENAN ALLGED ASSOCIATION BETWEEN

MENTAL ILLNESS & VIOLENCE (2)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

• 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)

Prevalence of mentalPrevalence of mentaldisorders in prisonersdisorders in prisoners

• Individuals suffering from schizophrenia; higher risk than general population to commit violent offence (Lindqvist & Allebeck 1990, and a large number of others)

• 12% of general psychiatric inpatients commit violent acts during the first year after discharge (Walsh et al 2001; Monahan et al 2001)

• Major mental disorder (incl. schz, major depression and bipolar syndrome) 2-6 times higher risk than healthy controls(Brennan 1996; Eronen et al 1996)

• An association with deinstitutionalisation?(Mullen et al 2000; 2004)

Violence in mentally disorderedViolence in mentally disordered

• ” 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’ ”

Mental Illness Violence?INTERPRETATION?INTERPRETATION?

IS THE GLASSHALF-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 THE CONTRIBUTION OF MENTAL DISORDER TO VIOLENT CRIME DISORDER TO VIOLENT CRIME

Martin Grann, PhD CPsych,Martin Grann, PhD CPsych, Associate Prof. 1) Honorary Research Fellow 2)

Seena Fazel, MB ChB MD MRCPsychSeena 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 riskDEFINITIONS

T

M

CCM-

CM-CM+

CM+

Individuals:

No of people in the population

No of people hospitalised with psych.diagnosis

No of people convicted of at leastone violent crime

People without psych hospitalisationswho were convicted

People with psych hospitalisationswho were convicted

M

T

C

DEFINITIONS (contd.)

T

M

CCM-

CM+

No of violent convictions:

No of violent convictions of peoplewithout psych. admissions

No of violent convictions of peoplewith psych. admissions

No of violent convictions

NCM-NCM-

NCM+NCM+

NCNC

NCNC NCM+NCM+NCM-NCM-= +

DEFINITIONS (contd.)

is the rate of violent crimes per 1000 persons in the populationT

r =

is the rate of violent crimes per 1000 non-disordered persons

NCNC

r0 = T-MNCM-NCM-

is the rate of violent crimes per 1000 mentally disordered personsr1 = M

NCM+NCM+

RR = r1/ r0 is the rate ratio

RD = r1- r0 is the rate difference (in rate per 1000)

RD% = (r1- r0) / r1 is the rate difference percent (%)

DEFINITIONS (contd.)

is the rate of convictions (rate per 1000 offenders) comitted by psychiatric patients

TNCNC

T-MNCM-NCM-PAR = r-r0 = -[ ] ][

PAF = PAR / r is the % of all convictions in the country comitted by psychiatric patients

Population attributable risk fraction

Population attributable risk

Note: PAR and PAF estimates assume that thereis a causal relationship between mental disorder and crime

RESULTS – RAW NUMBERS

T

M

CCM-

CM-CM+

CM+

Individuals 1988-2000:

M = 7 176 361 individuals in population >15

441,066 individuals were admitted on at leastone occasion for psych. diagnosis

145,860 individuals were convicted of at leastone violent crime

111,191 individuals without psych admissionwere convicted

34,635 individuals with psych admissionwere convicted

M

T

C

RESULTS – RAW NUMBERS

T

M

CCM-

CM+

No of violent crimes 1988-2000:

224,126 violent crimes by people without psych. admissions

114,330 violent crimes by people with psych. admissions

total 338,456 violent crimes

NCM-NCM-

NCM+NCM+

NCNC

RESULTS

Number of violent crimes per 1000 in the population

r = 45 / 1000

No of violent crimes (per 1000 in the population) committed by people identified as mentally disordered via the inpatient register

Population attributable riskPAR = 12 (out of 45)

1. Patients with severe mental illness (psychoses)

2. Substance use patients

1.) SEVERE MENTAL ILLNESSPsychoses

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 size

No. SMI patients

Total no. crimes committed

No. crimes committed by SMI patients

No. crimes committed by others

r

r0

r1

PAR per 1000

PAF

Age 15-24 Men 561 815 4 447 122 946 3 817 119 129 218.8 213.7 858.3 5.1 2.3% Women 586 683 3 520 8 784 304 8 480 15.0 14.5 86.4 0.4 2.9% Age 25-39 Men 930 121 12 633 113 794 9 109 104 685 122.3 114.1 721.1 8.2 6.7% Women 886 551 11 107 7 899 1 194 6 705 8.9 7.7 107.5 1.3 14.0% Age 40+ Men 1 998 512 26 321 65 625 5 605 60 020 32.8 30.4 213.0 2.4 7.3% Women 2 212 679 40 054 5 335 1 090 4 245 2.4 1.9 27.2 0.5 19.0% All ages, men 3 490 448 43 401 302 365 18 531 283 834 86.6 82.3 427.0 4.3 4.9% All ages, women 3 685 913 54 681 22 018 2 588 19 430 6.0 5.3 47.3 0.6 10.4% All ages, men and women

7 176 361 98 082 324 383 21 119 303 264 45.2 42.8 215.3 2.4 5.2%

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

Principal Diagnosis

No.

individuals

admitted to

hospital

No. crimes

committed

by

non-patients

No. crimes

committed

by

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 11.6%

Individual drug classes

Opiates 6,167 316,091 8,292 48.2 47.0 1344.6 1.2 2.5%

Cannabis 3,118 318,679 5,704 48.2 47.4 1829.4 0.8 1.7%

Sedatives 5,004 321,676 2,707 48.2 47.9 541.0 0.4 0.8%

Cocaine 196 323,992 391 48.2 48.2 1994.9 0.1 0.1%

Amphetamine 5,523 313,049 11,334 48.2 46.6 2052.1 1.6 3.4%

Hallucinogens 293 323,921 462 48.2 48.2 1576.8 0.1 0.1%

Solvents 368 323,791 592 48.2 48.2 1608.7 0.1 0.2%

Poly-drug misuse 13,413 303,446 20,937 48.2 45.2 1560.9 3.0 6.3%

Drug-induced psychosis 4,146 315,984 8,399 48.2 47.0 2025.8 1.2 2.5%

Alcohol and Drug Use(N = 144 146)

Grann & Fazel (2004) BMJ, 328, 1233-1234.

Any admission for alcohol or drug use: 23.3%

17.6%

Population-based studiesPopulation-based studiesSUMMARYSUMMARY

• 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.

CONCLUSIONCONCLUSION

• It makes sense to target the alcohol and drug clients for risk assessment and violence prevention programmes!