Individuals developing schizophrenia are hidden among adolescent substance misusers.

BACKGROUND: Strategies are needed to identify youth developing schizophrenia. The present study aimed to determine whether adolescents treated for substance misuse were at elevated risk to develop schizophrenia, whether this risk has changed since the late 1960s, and whether substance misuse in adolescence predicted poorer outcomes through adulthood. METHOD: In a Swedish city, since the mid-1960s there has been only one clinic for adolescent substance misuse. Three samples from this clinic were studied: 1992 individuals treated from 1968 to 1971 followed to age 50 years; 1576 treated from 1980 to 1984 followed to age 35 years; and 180 treated in 2004 followed to age 22 years. Each clinical sample was matched on age, sex and place of birth to an equal, or larger, number of randomly selected individuals from the general population. Schizophrenia, substance use disorders, physical disorders related to substance misuse, criminal convictions, poverty and death were identified using national registers. RESULTS: Individuals treated for substance misuse in adolescence were at increased risk to subsequently develop schizophrenia: in males the increase was approximately four-fold and in females between five- and seven-fold. There was no difference in risk for those treated in 1968-1971 and from 1980 to 1984 when cannabis use increased from 37.6% to 49.8% of the clinical samples. Among males who developed schizophrenia, treatment for substance misuse was associated with increased risk of substance use disorders and criminal convictions through adulthood. CONCLUSIONS: Treatment programmes for adolescents misusing substances include a disproportionate number developing schizophrenia. Early detection and treatment have the potential to improve long-term outcomes.

[Schizophrenia and violence]. / Schizophrenie und Gewalt.

BACKGROUND: There is now robust evidence that schizophrenia is associated with an increased risk of violence. Across Europe, the numbers of forensic hospital beds have dramatically increased largely due to admissions of men with schizophrenia. OBJECTIVE: This article critically reviews the extant literature on schizophrenia and violence. MATERIAL AND METHODS: A systematic review of the literature was carried out. RESULTS: People with schizophrenia are at increased risk, as compared to the general population, to be convicted for violent crimes because they are more likely to engage in aggressive behaviour towards others. While psychotic symptoms explain aggressive behaviour during acute episodes, they do not explain such behaviour at other stages of the illness or prior to onset of illness. Three distinct phenotypes of offenders with schizophrenia have been identified: individuals with a childhood onset of conduct disorder who display antisocial and aggressive behaviour both before and after schizophrenia onset, individuals with no history of conduct problems who begin engaging in aggressive behaviour at the onset of illness, and individuals who engage in a severe physical assault after many years of illness. Little is known about the aetiology of the three types of offenders and about the neural mechanisms that initiate and maintain these forms of behaviour. CONCLUSION: Mental health services need to assess the risk of violence among patients with schizophrenia and provide treatments that directly target antisocial and aggressive behaviour.

Meta-analyses of cognitive and motor function in youth aged 16 years and younger who subsequently develop schizophrenia.

BACKGROUND: Previous reviews have reported cognitive and motor deficits in childhood and adolescence among individuals who later develop schizophrenia. However, these reviews focused exclusively on studies of individuals with affected relatives or on population/birth cohorts, incorporated studies with estimated measures of pre-morbid intelligence, or included investigations that examined symptomatic at-risk participants or participants 18 years or older. Thus, it remains unclear whether cognitive and motor deficits constitute robust antecedents of schizophrenia. Meta-analyses were conducted on published studies that examined cognitive or motor function in youth aged 16 years or younger who later developed schizophrenia or a schizophrenia spectrum disorder (SSD) and those who did not. METHOD: Twenty-three studies fulfilled the following inclusion criteria: (1) written in English; (2) prospective investigations of birth or genetic high-risk cohorts, or follow-back investigations of population samples; (3) objective measures of cognitive or motor performance at age 16 or younger; (4) results provided for individuals who did and who did not develop schizophrenia/SSD later in life; and (5) sufficient data to calculate effect sizes. Four domains of function were examined: IQ; Motor Function; General Academic Achievement; and Mathematics Achievement. RESULTS: Meta-analyses showed that, by age 16, individuals who subsequently developed schizophrenia/SSD displayed significant deficits in IQ (d=0.51) and motor function (d=0.56), but not in general academic achievement (d=0.25) or mathematics achievement (d=0.21). Subsidiary analysis indicated that the IQ deficit was present by age 13. CONCLUSIONS: These results demonstrate that deficits in IQ and motor performance precede the prodrome and the onset of illness.

A multi-site randomized controlled trial of a cognitive skills programme for male mentally disordered offenders: social-cognitive outcomes.

BACKGROUND: Cognitive skills programmes have been associated with improvements on psychometric measures and reductions in antisocial behaviour in mentally disordered offenders (MDOs). However, to date there have been no randomized controlled trials (RCTs) of such programmes with this population. In the first RCT of a cognitive skills programme with MDOs we aimed to determine if participation in the Reasoning and Rehabilitation (R&R) programme was associated with improvements in social-cognitive skills and thinking styles. METHOD: A total of 84 men with a primary diagnosis of psychotic disorder and a history of violence were recruited from medium-secure forensic units and allocated to receive R&R (n=44) or treatment as usual (TAU; n=40). At baseline and post-treatment interviews, participants completed questionnaires to assess social problem-solving, criminal attitudes, anger experience, blame externalizing and perspective-taking. Researchers were not blind to group status. RESULTS: The R&R group demonstrated significant improvements on measures of social problem-solving relative to the TAU group, some of which were maintained at 12 months post-treatment. Only half of those allocated to receive R&R completed the full programme. In post-hoc analyses programme completers showed improvements in social problem-solving at the end of treatment and changes in criminal attitudes at 12 months post-treatment. CONCLUSIONS: Among male MDOs, R&R participation was associated with improvements in social-cognitive skills, some of which were maintained for up to 12 months post-treatment. Our finding that programme completers do better may reflect pre-treatment patient characteristics. This study establishes that multi-site RCTs can be conducted in medium-secure forensic units.

Movement abnormalities and psychotic-like experiences in childhood: markers of developing schizophrenia?

BACKGROUND: Both involuntary dyskinetic movements and psychotic-like experiences (PLEs) are reported to be antecedents of schizophrenia that may reflect dysfunctional dopaminergic activity in the striatum. The present study compared dyskinetic movement abnormalities displayed by children with multiple antecedents of schizophrenia (ASz), including speech and/or motor developmental lags or problems, internalising/externalising problems in the clinical range, and PLEs, with those displayed by children with no antecedents (noASz). METHOD: The sample included 21 ASz and 31 noASz children, aged 9-12 years old. None had taken psychotropic medication or had relatives with psychosis. The antecedents of schizophrenia were assessed using questionnaires completed by children and caregivers. A trained rater, blind to group status, coded dyskinetic movement abnormalities using a validated tool from videotapes of interviews with the children. RESULTS: ASz children reported, on average, 'certain experience' of 2.5 PLEs, while noASz children, by definition, reported none. The ASz children, as compared with noASz children, displayed significantly more dyskinetic movement abnormalities in total, and in the facial and the upper-body regions, after controlling for sex and age. Receiver operator characteristics analyses yielded high area under the curve values for the total score (0.94), facial score (0.91) and upper-body score (0.86), indicating that these scores distinguished between the ASz and noASz children with great accuracy. CONCLUSIONS: Brief questionnaires identified children with multiple antecedents of schizophrenia who displayed significantly more involuntary dyskinetic movement abnormalities than children without antecedents. The presence of PLEs and dyskinesias could reflect early disruption of striatal dopamine circuits.

Sensitivity to stress among the offspring of parents with bipolar disorder: a study of daytime cortisol levels.

BACKGROUND: It is well known that the hypothalamic-pituitary-adrenal (HPA) axis is compromised in major depression and bipolar disorder. There is increasing evidence that subtle HPA abnormalities, such as elevated cortisol levels, precede the development of an affective disorder. Interpersonal stress is also associated with the development of affective disorders. The present study sought to determine whether interpersonal chronic and episodic stress moderated the relationship between cortisol levels in the natural environment and risk status, defined as having a parent with bipolar disorder. METHOD: Sixty-two offspring of parents with bipolar disorder (OBD) and 60 offspring with no family history of affective disorders (OFH-), aged 19.48 years (s.d.=3.38, range 14-28), completed interviews assessing mental disorders and chronic and episodic stress, and provided saliva samples over 3 days. RESULTS: Regression analyses revealed that the OBD who experienced high interpersonal chronic stress displayed a larger cortisol rise following awakening than the OBD reporting low interpersonal chronic stress. The same relationship was also found for levels of non-interpersonal chronic stress. The OBD who reported experiencing severe interpersonal episodic stress exhibited higher levels of daytime cortisol than the OBD reporting interpersonal episodic stress of mild severity. Importantly, none of the above relationships were detected in the OFH-. Each of the interactions between family history of affective disorders and stress remained after controlling for age, gender and offspring lifetime affective disorders and current non-affective disorders. CONCLUSIONS: A biological sensitivity to stress may underlie the susceptibility to affective disorders among the OBD.

Multiple adverse outcomes over 30 years following adolescent substance misuse treatment.

OBJECTIVE: To compare outcomes over 30 years experienced by individuals who as adolescents entered substance misuse treatment and a general population sample. METHOD: All 1992 individuals seen at the only clinic for substance misusing adolescents in Stockholm from 1968 to 1971 were compared to 1992 individuals randomly selected from the Swedish population, matched for sex, age and birthplace. Death, hospitalization for physical illness related to substance misuse, hospitalization for mental illness, substance misuse, criminal convictions and poverty were documented from national registers. RESULTS: Relative risks of death, physical illness, mental illness, substance misuse, criminal convictions and poverty were significantly elevated in the clinic compared to the general population sample. After adjustment for substance misuse in adulthood, the risks of death, physical and mental illness, criminality and poverty remained elevated. CONCLUSION: Adolescents who consult for substance misuse problems are at high risk for multiple adverse outcomes over the subsequent 30 years.

Do community mental health teams caring for severely mentally ill patients adjust treatments and services based on patients' antisocial or criminal behaviours?

BACKGROUND: Antisocial behaviour is common among patients with severe mental illness (SMI) requiring hospitalisation. AIM: To determine whether differential treatments and services are provided to patients with SMI who engage in antisocial behaviour. METHOD: A random sample of 161 inpatients with SMI were recruited from general adult wards and assessed at baseline and two years later. Information on symptoms, aggressive behaviour, substance misuse, and service use was obtained from patients and clinical files. RESULTS: Past antisocial behaviours were not associated with type or intensity of treatments and services. Severity of positive symptoms, aggressive behaviour, and illicit drug use were positively associated with the frequency of CMHT contact, but not with the type of CMHT, type of medication, or other treatments and benefits. CONCLUSIONS: While the frequency of meetings with CMHTs increased with the severity of antisocial behaviours, no specific treatments were provided to patients with SMI engaging in antisocial behaviours.

From research to national expansion: 20 years' experience of community-based management of childhood pneumonia in Nepal.

PROBLEM: Pneumonia is a leading cause of mortality of children aged under five in Nepal. Research conducted by John Snow Inc. in the 1980s determined that pneumonia case management by community-based workers decreased under-five mortality by 28%. APPROACH: Female community health volunteers were selected as the national cadre to manage childhood pneumonia at community level using oral antibiotics. A technical working group composed of government officials, local experts and donor partners embarked on a process to develop a strategy to pilot the approach and expand it nationally. LOCAL SETTING: High under-five mortality rates, low access to peripheral health facilities and severe constraints in human resources led Nepal's Ministry of Health to test this innovative approach. RELEVANT CHANGES: Community-based management of pneumonia doubled the total number of cases treated compared with districts with facility-based treatment only. Over half of the cases were treated by the female community health volunteers. The programme was phased in over 14 years and now 69% of Nepal's under-five population has access to pneumonia treatment. LESSONS LEARNED: Community-based management of pneumonia provides a medium-term solution to address a leading cause of child mortality while the efforts continue to strengthen and extend the reach of facility-based care. Trained community health workers can significantly increase the number of pneumonia cases receiving correct case management in resource-constrained settings, with appropriate health systems' support for logistics, supervision and monitoring. Community-based management of pneumonia can be scaled up and provides an effective approach to reducing child deaths in countries faced with insufficient human resources for health.

Violent persons with schizophrenia and comorbid disorders: a functional magnetic resonance imaging study.

The main goal of this functional Magnetic Resonance Imaging (fMRI) study was to verify the hypothesis that seriously violent persons with Sz and the co-morbid diagnoses of an Antisocial Personality Disorder (APD) and a Substance Use Disorder (Sz+APD+SUD) would present a different pattern of prefrontal functioning than seriously violent persons with Sz only. In support with the main hypothesis, frontal basal cortices were significantly less activated in persons with Sz+APD+SUD during the execution of a go/no-go task than in persons with Sz only and non-violent persons without a mental illness. In contrast, significantly higher activations in frontal motor, premotor and anterior cingulate regions were observed in the Sz+APD+SUD group than in the Sz-only group.

Conduct disorder in females is associated with reduced corpus callosum structural integrity independent of comorbid disorders and exposure to maltreatment.

The behavioral phenotype and genotype of conduct disorder (CD) differ in males and females. Abnormalities of white matter integrity have been reported among males with CD and antisocial personality disorder (ASPD). Little is known about white matter integrity in females with CD. The present study aimed to determine whether abnormalities of white matter are present among young women who presented CD before the age of 15, and whether abnormalities are independent of the multiple comorbid disorders and experiences of maltreatment characterizing females with CD that may each in themselves be associated with alterations of the white matter. Three groups of women, aged on average 24 years, were scanned using diffusion tensor imaging and compared: 28 with prior CD, three of whom presented ASPD; a clinical comparison (CC) group of 15 women with no history of CD but with similar proportions who presented alcohol dependence, drug dependence, anxiety disorders, depression disorders and physical and sexual abuse as the CD group; and 24 healthy women. Whole-brain, tract-based spatial statistics were computed to investigate differences in fractional anisotropy, axial diffusivity and radial diffusivity. Compared with healthy women, women with prior CD showed widespread reductions in axial diffusivity primarily in frontotemporal regions. After statistically adjusting for comorbid disorders and maltreatment, group differences in the corpus callosum body and genu (including forceps minor) remained significant. Compared with the CC group, women with CD showed reduced fractional anisotropy in the body and genu of the corpus callosum. No differences were detected between the CD and healthy women in the uncinate fasciculus.

Mental disorder, intellectual deficiency, and crime. Evidence from a birth cohort.

Studies of criminality among patients in psychiatric hospitals and of mental disorder among incarcerated offenders have suggested an association between the major mental disorders (schizophrenia and major affective disorders) and crime. However, these investigations are characterized by notable methodological weaknesses, and, consequently, this conclusion has remained tentative. Little is known about the criminality of intellectually handicapped people. The present study examined the relationship between crime and mental disorder and crime and intellectual deficiency in an unselected Swedish birth cohort followed up to age 30 years. It was found that men with major mental disorders were 2 1/2 times more likely than men with no disorder or handicap to be registered for a criminal offense and four times more likely to be registered for a violent offense. Women with major disorders were five times more likely than women with no disorder or handicap to be registered for an offense and 27 times more likely to be registered for a violent offense. These subjects committed many serious offenses throughout their lives. The criminal behavior in over half these cases appeared before the age of 18 years. Intellectually handicapped men were three times more likely to offend than men with no disorder or handicap and five times more likely to commit a violent offense. Intellectually handicapped women were almost four times more likely to offend than women with no disorder or handicap and 25 times more likely to commit a violent offense.(ABSTRACT TRUNCATED AT 250 WORDS)

Major mental disorders and criminal violence in a Danish birth cohort.

BACKGROUND: This epidemiological investigation was designed to examine the relationships between each of the major mental disorders and criminal violence. Specifically, we assessed whether a significant relationship exists between violence and hospitalization for a major mental disorder, and whether this relationship differs for schizophrenia, affective psychoses, and organic brain syndromes. METHODS: Subjects were drawn from a birth cohort of all individuals born between January 1, 1944, and December 31, 1947, in Denmark (N = 358 180). Because of the existence of accurate and complete national registers, data were available on all arrests for violence and all hospitalizations for mental illness that occurred for individuals in this cohort through the age of 44 years. RESULTS: There was a significant positive relationship between the major mental disorders that led to hospitalization and criminal violence (odds ratios 2.0-8.8 for men and 3.9-23.2 for women). Persons hospitalized for a major mental disorder were responsible for a disproportionate percentage of violence committed by the members of the birth cohort. Men with organic psychoses and both men and women with schizophrenia were significantly more likely to be arrested for criminal violence than were persons who had never been hospitalized, even when controlling for demographic factors, substance abuse, and personality disorders. CONCLUSIONS: Individuals hospitalized for schizophrenia and men hospitalized with organic psychosis have higher rates of arrests for violence than those never hospitalized. This relationship cannot be fully explained by demographic factors or comorbid substance abuse.

Obstetric complications, parenting, and risk of criminal behavior.

BACKGROUND: The results of studies that have examined the relationship between prenatal and perinatal complications and adult criminality and violence are contradictory. Supporting evidence for this relationship comes from studies of samples drawn from a single cohort. The present study was designed to examine the associations between prenatal and perinatal complications and criminality, defining more precisely than past investigations subject characteristics and the types of offenses. METHODS: The cohort includes the 15 117 persons born in Stockholm, Sweden, in 1953 and followed up to age 30 years. Information was extracted from obstetric files, health, social, work, and criminal records. Obstetric complications were defined as deviations from normal development occurring at any point from conception through the neonatal period. Inadequate parenting was indexed by social intervention. RESULTS: Inadequate parenting was experienced by 19.1% of the men and 18.1% of the women, and was shown to increase the risk of offending (men, 1.39 times [95% confidence interval [CI], 1.28-1.50]; women, 2.09 [95% CI, 1.70-2.56]) and of violent offending (men, 2.02 times [95% CI, 1.67-2.44]; women, 2.09 [95% CI, 1.70-2.56]). Obstetric complications in the absence of family problems did not increase the risk of offending. A combination of pregnancy complications and inadequate parenting affected 3.1% of the men and 4.0% of the women, and increased the risk of offending (1.64 times [95% CI, 1.43-1.89]; 1.79 times [95% CI, 1.16-2.75], respectively) and violent offending (2.86 times [95% CI, 2.09-3.91]; 1.81 times [95% CI, 0.57-5.79]). CONCLUSIONS: A combination of pregnancy complications and inadequate parenting increased the risk of violent and nonviolent offending only slightly more than inadequate parenting alone. However, inadequate parenting was experienced by 5 times more cohort members than was the combination of inadequate parenting and pregnancy complications.

Mental disorder and crime. Evidence from a Danish birth cohort.

BACKGROUND: Evidence has accumulated since the mid 1960s from a number of different countries indicating an association between mental disorder and crime and particularly between the major mental disorders and violence. Registries in Denmark were used to identify a birth cohort and to document all psychiatric admissions and all criminal proceedings of the 324401 members of this cohort up to the age of 43 years. METHODS: Persons who had been admitted to a psychiatric ward were assigned to a diagnostic category according to a hierarchy of principal discharge diagnoses. They were compared with persons never admitted to a psychiatric ward as to the prevalence, type, and frequency of criminal convictions. RESULTS: Women and men who had been hospitalized in psychiatric wards were more likely to have been convicted of a criminal offense than persons with no history of psychiatric hospitalization. The offenders who were hospitalized committed all types and, on average, as many offenses as did the never-hospitalized group of the same sex. CONCLUSIONS: These findings confirm those from 2 other post-World War II Scandinavian birth cohorts that have found an association between psychiatric hospitalization and criminal convictions. They also concur with findings that patients discharged from psychiatric wards are more likely than other persons living in the same community to commit crimes and with results from North America showing elevated rates of major mental disorders among incarcerated offenders. Generalization of these findings is limited to nations with similar criminal justice, mental health, and social welfare systems.

Male criminals with organic brain syndrome: two distinct types based on age at first arrest.

OBJECTIVE: This study examined whether criminals with organic brain syndrome could be divided into two distinct types. The authors proposed that early starters (onset of criminal activity by age 18) would display a persistent, long-lasting pattern of deviance that was largely independent of their brain disorder, whereas late starters (onset at age 19 or after) would exhibit deviant behaviors that began late in life and were more directly related to their brain disorder. METHOD: Subjects were 1,130 male criminal offenders drawn from a birth cohort of all individuals born between January 1, 1944, and December 31, 1947, in Denmark. The main study group included all men with both a history of criminal arrest and a hospitalization for organic brain syndrome (N=565). In addition, for a subset of analyses, the authors examined a randomly selected, same-size comparison group of men with a history of criminal arrest who were not hospitalized for organic brain syndrome. Data were available on all arrests and all psychiatric hospitalizations for individuals in this cohort through the age of 44. RESULTS: Among those with organic brain syndrome, early starters were significantly more likely than late starters to 1) be arrested before the onset of organic brain syndrome, 2) show a higher rate of offending before but not after the onset of organic brain syndrome, 3) be both recidivists and violent recidivists, and 4) have a diagnosis of antisocial personality disorder. CONCLUSIONS: Male criminals with organic brain syndrome can be meaningfully divided into two distinct types on the basis of age at first arrest. Early starters show a more global, persistent, and stable pattern of offending than late starters. These results have implications for treatment and risk assessment.

Maternal smoking during pregnancy and risk of criminal behavior among adult male offspring in the Northern Finland 1966 Birth Cohort.

OBJECTIVE: The goal of this study was to test the hypothesis that maternal smoking during pregnancy is associated with greater risk for criminal behavior of the offspring in adulthood. METHOD: An unselected, general population cohort composed of 11,017 subjects (5,636 men, 5,381 women) was followed up prospectively from the sixth month of pregnancy to age 28 years. Interviews with the mother during the pregnancy, health records, and an assessment of the offspring at age 1 year provided information on risk factors. The Ministry of Justice provided information on criminal offenses for all subjects. RESULTS: Because of the low rate of criminal offenses among women, the present analyses are restricted to men (N = 5,636). Compared to the sons of mothers who did not smoke, the sons of mothers who smoked during pregnancy had more than a twofold risk of having committed a violent crime or having repeatedly committed crimes, even when other biopsychosocial risk factors were controlled. While maternal smoking during pregnancy alone explained 4% of the variance associated with violent offenses among male offspring, it was not significantly associated with nonviolent offenses among male offspring. When maternal smoking during pregnancy was combined with a maternal age of less than 20 years, a single-parent family, an unwanted pregnancy, and a developmental lag in walking or talking, the odds ratios for violent offenses increased up to ninefold and for persistent offenses up to 14-fold. CONCLUSIONS: Maternal smoking during pregnancy is associated with violent offenses and persistent offenses, but not with nonviolent offenses, among male offspring in adulthood.

Ventral frontal deficits in psychopathy: neuropsychological test findings.

The hypothesis of prefrontal dysfunction in psychopathy has been pursued for many years, without convincing results. It is proposed here that this approach in previous studies was far too global. The present investigation was carried out in order to test a more specific hypothesis of orbitofrontal and/or frontal ventromedial deficits in psychopathy. Psychopathic criminals were compared to non-psychopathic criminals with measures related to orbitofrontal or frontal ventromedial functioning, as well as with control measures more associated with frontodorsolateral and posterorolandic functions. All subjects provided urine samples for drug assay. It was found that, while the two groups performed similarly on all the control measures, including the drug tests, the psychopaths were significantly impaired on all the orbitofrontal-ventromedial tasks. The psychopaths were significantly impulsive on several tests as well as significantly dysosmic [corrected]. The latter finding is particularly important in the sense that it cannot readily be explained socioculturally, thus presenting a new and convincing argument for brain-based etiology of this disorder. The results are discussed in relation to other psychiatric disorders characterized by impulse dyscontrol as well as in relation to other putative neurobiological etiological factors in psychopathy.

High levels of cortisol among adolescent offspring of parents with bipolar disorder: a pilot study.

The hypothalamic-pituitary-adrenal (HPA) axis is compromised at several levels in major depressive and bipolar disorder (BD). However, it is not known whether HPA abnormalities predate the onset of these disorders. We conducted a pilot study comparing salivary cortisol levels of 10 adolescent offspring of parents with BD and 10 offspring of parents with no mental disorder (NMD). For two days, samples were collected at awakening and during the day in the adolescents' natural environment. The offspring of parents with BD had higher mean cortisol levels in the mornings and afternoons than the offspring of parents with NMD. When controlling for age, group differences in cortisol persisted in the afternoon, but not morning samples. None of the adolescents met diagnostic criteria for anxiety, affective, attention-deficit, or conduct disorders. Although preliminary, the results suggest that there is an early abnormality in the HPA system of the offspring of parents with BD.