Exploring a new structured professional judgment measure (impulsivity measure related to violence) after an average follow-up of 10 years: A study of Finnish offenders.

BACKGROUND: Identification of the risk factors underlying impulsivity related to violent acts is an essential component of risk assessment and management to reduce violent offending. AIMS: Our aim was to develop a clinically useful measure for assessing impulsivity related to violence. Our research questions were which items in the newly developed measure are associated with later violent recidivism and what is the measure's predictive validity? METHODS: A new scale, the impulsivity measure related to violence (IMP-V), was studied by completing the scale, blind to outcome, from information in the forensic psychiatric examination reports of 63 of a 1-year referral cohort of 181 Finnish offenders. Data on reoffending for up to 15 years after release were collected from official criminal records. RESULTS: The predictive accuracy of the IMP-V continuous ratings was 78% and for the categorical summary risk ratings 77%. Univariate analyses of categorical summary risk ratings of the risk factors revealed that, with two exceptions, each additional score on the IMP-V was associated with a significant increase in violence recidivism. CONCLUSIONS: These preliminary results indicate that the IMP-V is a promising decision-enhancing guide for assessing the risk of violence in impulsive people and that the measure is worth developing for use with impulsivity-prone offenders and forensic psychiatric patients. The IMP-V organises information on the nature of impulsivity in violence-prone persons and thus also creates opportunities for more effective risk management.

Changes in patient safety culture: A patient safety intervention for Finnish forensic psychiatric hospital staff.

AIM: To evaluate how a 3-year patient safety intervention, more specifically, the implementation of a patient safety incident reporting system, influences patient safety culture. BACKGROUND: Positive patient safety culture improves both the quality of health care and patient safety. Nevertheless, nursing managers need tools that can help them develop and evaluate patient safety culture. METHODS: The Hospital Survey on Patient Safety Culture was used to evaluate patient safety culture at two Finnish forensic psychiatric hospitals (study and control) over two periods, baseline and follow-up. Data were analysed using Z-score and T test statistics. RESULTS: The follow-up results from the study hospital showed that five patient safety culture dimensions exhibited a significantly (p < 0.05) positive change in positive response rates over the 3-year period. Furthermore, nine out of twelve patient safety culture dimensions at the study hospital showed a significant improvement in mean score. At the control hospital, only the dimension of frequency of reporting events showed a significantly positive change (p < 0.05) in mean score. CONCLUSION: This research shows that the studied patient safety intervention (implementation of the patient safety incident reporting system) significantly influences patient safety culture. IMPLICATIONS FOR NURSING MANAGEMENT: Nursing managers should utilize a variety of patient safety interventions to improve patient safety and focus on leveraging information from patient safety incidents to advance patient safety culture.

Is there an interrelationship between the effects of antipsychotics on psychopathology and on metabolism?

BACKGROUND: Increased body weight and hyperlipidemia caused by antipsychotics may be associated with improved antipsychotic efficacy in schizophrenia. If this association has a causal interrelationship via a genuine pathophysiological mechanism, then body weight loss in antipsychotic-treated patients would be accompanied by worsened psychopathology. This could have clinical implications. AIM: To explore whether the decreased body weight in these patients is associated with a worsened psychopathology. METHODS: In our previously published study, a 16 week treatment period with add-on orlistat (but not placebo) resulted in body weight loss in male (but not female) clozapine- or olanzapine-treated overweight or obese patients. In the current study, we investigated whether body weight loss in those male patients could worsen psychosis. Changes in the Positive and Negative Syndrome Scale (PANSS) scores within groups and body weight changes and lipid profiles over the treatment period were analysed by the paired samples t-test. Between-group comparisons were analysed by the independent samples t-test. RESULTS: Over the treatment period body weight decreased by 2.56 ± 3.25 kg from initial 106.02 ± 12.61 kg (p = 0.04) for the orlistat group, with no statistically significant changes for the placebo group. Lipid levels did not change in either group. The orlistat-induced weight decrease was not associated with worsening in the PANSS scores. CONCLUSIONS: Weight loss was not associated with a worsening of psychosis. The interrelationship between the antipsychotic-induced weigh gain and improved schizophrenia psychopathology observed in earlier studies appears to be indirect. Orlistat treatment in our study did not worsen psychopathology in this population.

Predictive validity of the structured assessment of violence risk in youth: A 4-year follow-up.

BACKGROUND: Structured violence risk assessment is an essential part of treatment planning for violent young people. The Structured Assessment of Violence Risk in Youth (SAVRY) has been shown to have good reliability and validity in a range of settings but has hardly been studied in adolescent mental health services. AIMS: This study aimed to evaluate the long-term predictive validity of the SAVRY in adolescent psychiatry settings. METHODS: In a prospective study, 200 SAVRY assessments of adolescents were acquired from psychiatric, forensic and correctional settings. Re-offending records from the Finnish National Crime Register were collected. Receiver operating curve statistics were applied. RESULTS: High SAVRY total and individual subscale scores and low values on the protective factor subscale were significantly associated with subsequent adverse outcomes, but the predictive value of the total score was weak. At the risk item level, those indicating antisocial lifestyle, absence of social support and pro-social involvement were strong indicators of subsequent criminal convictions, with or without violence. The SAVRY summary risk rating was the best indicator of likelihood of being convicted of a violent crime. After allowing for sex, age, psychiatric diagnosis and treatment setting, for example, conviction for a violent crime was over nine times more likely among those young people given high SAVRY summary risk ratings. CONCLUSIONS: The SAVRY is a valid and useful method for assessing both short-term and long-term risks of violent and non-violent crime by young people in psychiatric as well as criminal justice settings, adding to a traditional risk-centred assessment approach by also indicating where future preventive treatment efforts should be targeted. The next steps should be to evaluate its role in everyday clinical practice when using the knowledge generated to inform and monitor management and treatment strategies.

[Adolescents engaging in sexually offending behavior]. / Vahingoittavaan seksuaalikäyttäytymiseen syyllistyvät nuoret.

Sexually offending behavior by adolescents may be directed towards children, age-mates and adults. Neurocognitive and psychiatric disorders and the associated inability to age-related interpersonal relationships and inability to control the sexual desires activated during adolescence may lead a young person to seek inappropriate sexual satisfaction from children. Sometimes the offenses are part of antisocial development. Interventions should be focused on the distorted cognitions and attitudes maintaining the injurious sexual behavior, and on the risk of criminal behavior in general. Pharmacological therapy, mainly with SSRI drugs, has also been tested in adolescents.

Potential predictors in neonaticide: the impact of the circumstances of pregnancy.

This study aims to evaluate the psychosocial factors of neonaticide, especially the circumstances before delivery, the relationships of the pregnant women, and their social environment awareness of women's pregnancy. This nationwide study was register-based, comprising all known neonaticides in Austria and Finland between 1995 and 2005. Cases (n = 28) were obtained by screening the death certificates from coroner's departments and by analyzing them along with all further available reports. Few women (17.9 %, 5/28) admitted their pregnancy to others. Although most (16/28) offenders were in a relationship, the partner had knowledge of the pregnancy in only three cases. The main motive for negation of the pregnancy (named in 60.8 % of cases) was fear of abandonment/negative response from others. The fertility rate among the women was high, but half of those with children had lost the custody of them. In neonaticide, the lack of awareness surrounding offenders' pregnancy, as well as the awareness of social environment, is more relevant than any other social variable.

Nurses' Views Highlight a Need for the Systematic Development of Patient Safety Culture in Forensic Psychiatry Nursing.

BACKGROUND: Although forensic nurses work with the most challenging psychiatric patients and manifest a safety culture in their interactions with patients, there have been few studies on patient safety culture in forensic psychiatric nursing. OBJECTIVES: The aim of this qualitative study was to describe nurses' views of patient safety culture in their working unit and daily hospital work in 2 forensic hospitals in Finland. METHODS: Data were collected over a period of 1 month by inviting nurses to answer an open-ended question in an anonymous Web-based questionnaire. A qualitative inductive analysis was performed on nurses' (n = 72) written descriptions of patient safety culture in state-owned forensic hospitals where most Finnish forensic patients are treated. RESULTS: Six main themes were identified: "systematization of an open and trusting communication culture," "visible and close interaction between managers and staff," "nonpunitive responses to errors, learning and developing," "balancing staff and patient perspectives on safety culture," "operational safety guidelines," and "adequate human resources to ensure safety." CONCLUSIONS: The findings highlight the influence of the prevailing culture on safety behaviors and outcomes for both healthcare workers and patients. Additionally, they underline the importance of an open culture with open communication and protocols.

Who are the restrained and secluded patients: a 15-year nationwide study.

BACKGROUND: To find interventions for reducing the use of restraint and seclusion, it is necessary to identify who the restrained and secluded patients are. The aim of the present study was to determine which demographic and clinical groups of psychiatric inpatients are at risk of being restrained/secluded, and whether there have been changes in the restrained/secluded patients' profiles over a 15-year period in Finland. METHOD: A structured postal survey concerning the demographic and clinical information of restrained/secluded patients was completed in all Finnish psychiatric hospitals during a predetermined week in 1990, 1991, 1994, 1998, and 2004. The National Hospital Discharge Register was used to gather information on all psychiatric inpatients during the study weeks. RESULTS: Out of the variables studied (age, gender, main diagnosis, phase of hospital stay), only the main diagnosis and the phase of hospital stay were independent risk factors for restraint/seclusion, and remained constant over time. The age profile of the restrained/secluded patients was unstable over time and the risk of being restrained/secluded was not associated with gender. CONCLUSION: Restraint and seclusion is used mainly among the acute and the most disturbed patients. Therefore, in order to reduce the use of restraint and seclusion, resources should be targeted especially to these groups.

The reasons for using restraint and seclusion in psychiatric inpatient care: A nationwide 15-year study.

BACKGROUND: The containment or the prevention of actual violence is the primary justification for the use of restraint and seclusion in psychiatry. The aim of the present study was to determine the grounds for using restraint and seclusion in clinical practice in Finland, and whether these reasons have changed over a 15-year period as a result of legislative changes. METHOD: A structured postal survey concerning the reasons for restraint and seclusion was completed in all the Finnish psychiatric hospitals during a predetermined week in 1990, 1991, 1994, 1998 and 2004. The duration of the episode as well as demographic and clinical information on the restrained and secluded patient were also reported. RESULTS: Agitation/disorientation was the most frequent reason for the use of restraint and seclusion. The duration of the restraint and seclusion episodes was not determined by the reason for using these measures. Some differences in the reasons were found among subgroups of patients. CONCLUSION: Clinical practice deviates from the theoretical and legal grounds established for restraint and seclusion, and is too open to subjective assessment and interpretations.

Differences between homicide and filicide offenders; results of a nationwide register-based case-control study.

BACKGROUND: Filicide, the killing of one's child, is an extraordinary form of homicide. It has commonly been associated with suicide and parental psychiatric illness. In the research on filicide, nationwide studies with comparison groups, specific perpetrator subgroups, and assessment of possible risk factors have been called for. The purpose of the current study was to provide all that. METHODS: In this nationwide register-based case-control study all filicide offenders who were in a forensic psychiatric examination in Finland 1995-2004 were examined and compared with an age- and gender matched control group of homicide offenders. The assessed variables were psychosocial history, index offence, and psychiatric variables as well as psychopathy using the PCL-R. RESULTS: Filicide offenders were not significantly more often diagnosed with psychotic disorders than the controls but they had attempted suicide at the crime scene significantly more often. Filicide offenders had alcohol abuse/dependence and antisocial personality less often than the controls. Filicide offenders scored significantly lower on psychopathy than the controls. Within the group of filicide offenders, the psychopathy items with relatively higher scores were lack of remorse or guilt, shallow affect, callous/lack of empathy, poor behavioral controls, and failure to accept responsibility. CONCLUSION: Since filicide offenders did not seem significantly more mentally disordered than the other homicide offenders, psychiatry alone cannot be held responsible for the prevention of filicide. Extensive international studies are needed to replicate our findings and provide more specific knowledge in order to enhance prevention.

Filicide in Austria and Finland--a register-based study on all filicide cases in Austria and Finland 1995-2005.

BACKGROUND: Filicide is the tragic crime of murdering one's own child. Previous research has found that the offending parents are commonly depressed and that suicide is often associated as an actual act or an intention. Yet, filicide is an underreported crime and previous studies have been strained with methodological problems. No comprehensive international studies on filicide have been presented in the literature until now. METHODS: This was a descriptive, comprehensive, register-based study of all filicides in Austria and Finland during 1995-2005. Filicide-suicide cases were also included. RESULTS: Most of the perpetrators were the biological mothers; in Austria 72%, in Finland 52%. Suicide followed filicide either as an attempt or a fulfilled act in 32% and 54% of the cases in Austria and Finland, respectively. Psychotic mood disorders were diagnosed for 10% of the living perpetrators in Austria, and 12% in Finland. Non-psychotic depression was diagnosed in 9% of surviving perpetrators in Austria, 35% in Finland. CONCLUSION: The data from the two countries demonstrated that filicide is such a multifaceted and rare phenomenon that national data from individual countries seldom offer sufficient scope for its thorough study. Further analyses are needed to produce a complete picture of filicide.

Intoxication and violent women.

Alcohol and drugs have been linked to severe violent offending among women as well as men. The purpose of this study was to make a contribution to the limited knowledge of characteristics related to the state of intoxication in violent female offenders. The putative differences in the characteristics of female offenders and their violent offenses in relation to the state of intoxication at the time of the violent offending were examined. Of a nation-wide sample of 109 female offenders found guilty of homicide and other violent crimes and incarcerated in 1999-2000 in Finland, 60 offenders participated in the study. Of these offenders 49 (81.7%) had been intoxicated at the time the of index offenses. These were compared with 11 (18.3%) non-intoxicated offenders using a structured interview, the Structured Clinical Interview II for DSM-IV (SCID-II) and the Hare Psychopathy Checklist-Revised (PCL-R). The prevalence of substance abuse or dependence (73.3% and 0%), personality disorder (89.6% and 36.4%), particularly antisocial personality disorder (66.7% and 0%), as well as a history of criminality (69.4% and 0%) were significantly higher among the intoxicated women than among the non-intoxicated. The PCL-R scores were also significantly higher among the intoxicated offenders than among non-intoxicated offenders. The victims of the intoxicated women (23.9%) were less often emotionally close to the perpetrator than were the victims of the non-intoxicated women (66.6%). No differences emerged between the groups in experiences of childhood and adulthood abuse or stressful life events prior to the index crime. The findings indicate that intoxicated violent female offenders exhibit more of the characteristics previously found in violent men, than do the non-intoxicated female offenders. Moreover, the non-intoxicated group comprises both psychotic non-responsible and non-psychotic, fairly well-adjusted women, who are educated, working or studying at the time of the offense and has no history of criminality. Substance misuse constitutes an obvious risk factor for violent behavior in women, and therefore the prevention should include substance abuse treatment.

[Filicides in Finland]. / Vanhempien lapsiinsa kohdistamat henkirikokset Suomessa.

BACKGROUND: Filicides have decreased in Finland. MATERIALS AND METHODS: All filicides (child homicides by parents) in Finland during 1995-2005 were elucidated in a register study. The material consisted of 50 parents of 66 killed children. RESULTS: Altogether 15 parents also committed suicide. After the deed, 31 parents were subjected to psychiatric examination; ten out of them had a psychotic disorder. A personality disorder was found in 16 parents and a non-psychotic affective disorder in 12 parents. CONCLUSIONS: Homicidal parents differ from other homicidal persons. Prevention of suicides is also expected to prevent homicide mortality among children.

Legal outcomes of all suspected neonaticides in Finland 1980-2000.

This nationwide study examined legal outcomes and possible psychiatric diagnoses of suspected cases of neonaticide. Neonaticide is commonly defined as the killing of a newborn on the day of its birth, and is considered to have not only a low prevalence but also a high level of concealed criminality. This hidden nature guided us to find out what the final legal outcomes of suspected neonaticide were. It was a comprehensive, retrospective, register-based study of all 44 cases of suspected neonaticide that occurred 1980-2000 as recorded by Statistics Finland. The 44 cases were ascribed to 40 suspects, three of whom died themselves during the offence. Twelve cases (27%) were eventually prosecuted and the accused convicted of neonaticide. Their mean sentence was 617 days (SD 216, range 300-1095 days). Fourteen offenders (35% of offenders) underwent a forensic psychiatric examination, out of which four (29%) were diagnosed with a psychotic disorder and 10 (71%) with a personality disorder. Six of the 14 women were not sentenced as criminally irresponsible and three of them were committed to involuntary hospital care. Nine cases (20% of cases) were still unsolved, and in eight (18%) cases the offence title had changed into something other than neonaticide. We concluded that since only 41% of suspected neonaticides completed the court process as neonaticides, the previous results from studies on neonaticide may present a subgroup of offenders, not the whole picture. Therefore, further discussion and research is needed to elucidate this perplexing, sad, and utterly redundant offence in modern society, to prevent it, and develop treatment programs for the offenders.

Sleep architecture in homicidal women with antisocial personality disorder--a preliminary study.

The aim of the present study was to characterize sleep in severely violent women with antisocial personality disorder (ASP) as the primary diagnosis. Participants for this preliminary study were three drug-free female offenders ordered to undergo a forensic mental examination in a maximum security state mental hospital after committing homicide or attempted homicide. Ten healthy age- and gender-matched controls consisted of hospital staff with no history of physical violence. The most striking finding was the increased amount of slow wave sleep, particularly the deepest sleep stage, S4, in women with ASP. This finding is in agreement with previously reported results in habitually violent male criminals with ASP. Severe female aggression seems to be associated with profound changes in sleep architecture. Whether this reflects specific brain pathology, or a delay in the normal development of sleep patterns in the course of aging, needs to be clarified. From the perspective of sleep research, the biological correlates of severe impulsive violence seem to be similar in both sexes.

Topiramate add-on in treatment-resistant schizophrenia: a randomized, double-blind, placebo-controlled, crossover trial.

OBJECTIVE: We tested the hypothesis that topiramate is more effective than placebo in reducing symptoms in patients with treatment-resistant schizophrenia when combined with ongoing antipsychotic medication. METHOD: Twenty-six hospitalized treatment-resistant patients with chronic DSM-IV-diagnosed schizophrenia participated in a randomized, double-blind, placebo-controlled trial in which 300 mg/day of topiramate was gradually added to their ongoing treatment (clozapine, olanzapine, risperidone, or quetiapine) over two 12-week crossover treatment periods. Data were collected from April 2003 to November 2003. RESULTS: In intention-to-treat analysis, topiramate was more effective than placebo in reducing Positive and Negative Syndrome Scale general psychopathologic symptoms (effect size = 0.7, p = .021), whereas no significant improvement was observed in positive or negative symptoms. CONCLUSION: Glutamate antagonist topiramate may be an effective adjuvant treatment in reducing general psychopathologic symptoms in patients with schizophrenia resistant to treatment with second-generation antipsychotics.

Lamotrigine in treatment-resistant schizophrenia: a randomized placebo-controlled crossover trial.

BACKGROUND: There is no evidence from randomized, controlled trials that demonstrate effectiveness for any pharmacological treatment in clozapine-resistant schizophrenia. Since the introduction of chlorpromazine, all antipsychotics with proven efficacy on positive symptoms have been dopamine antagonists, but recent experimental data suggest that ketamine-induced positive schizophreniform symptoms in healthy subjects can be controlled by a glutamate antagonist lamotrigine. The hypothesis tested was that lamotrigine is more effective than placebo in the treatment of positive schizophrenic symptoms when combined with clozapine. METHODS: Thirty-four hospitalized treatment-resistant patients having chronic schizophrenia participated in a double-blind, placebo-controlled, 14-week, crossover trial where 200 mg/day lamotrigine was gradually added to their ongoing clozapine treatment. Clinical assessments were made by the Positive and Negative Syndrome Scale at the beginning and end of each treatment period. RESULTS: In intention-to-treat analysis, lamotrigine treatment was more effective in reducing positive (effect size.7, p =.009) and general psychopathological (effect size.6, p =.030) symptoms, whereas no improvement was observed in negative symptoms. CONCLUSIONS: These results provide the first evidence from a randomized controlled trial of an effective pharmacological treatment with an anticonvulsant agent in treatment-resistant schizophrenia and indicate that both positive and general psychopathological symptoms in patients with schizophrenia can be controlled by a drug that is not a dopamine antagonist. The results are in line with previous experimental data suggesting that excessive glutamate neurotransmission contributes to the positive symptoms of schizophrenia.

Risk of repeat offending among violent female offenders with psychotic and personality disorders.

OBJECTIVE: The aim of this study was to examine the rate of criminal recidivism among female homicide offenders evaluated by forensic psychiatrists, to compare this rate with that of other violent female offenders, and to analyze the explanatory variables of recidivism. METHOD: This was a retrospective study of all women (N=132) sent for forensic psychiatric examination after being convicted of homicide or attempted homicide in Finland during 1982-1992; subjects were followed up until mid-1999. Data were collected from the national crime register, the prisoner record, and Statistics Finland. The authors compared the rate of violent repeat offending in this group with that of other violent women and analyzed the explanatory variables of recidivism. RESULTS: During the follow-up period, 23% of the study group committed a repeat offense, 15% of which were violent and 3% of which were homicides. Almost half of all repeat offenses occurred within the first 2 years after the index offense. There was no statistically significant difference in violent recidivism between the study group and other violent female offenders. Of those who committed repeat offenses, 81% were diagnosed with a personality disorder, and 10% were diagnosed with psychosis. Criminality prior to the index event, alcohol or drug dependency, and young age significantly raised the risk and rapidity of further offenses. CONCLUSIONS: The risk of recidivism was high in this study group yet was similar to that of other violent female offenders. The risk was high very early after release. It seems that women and men who are violent and have personality disorders are comparable in their risk of recidivism.