The current state of psychiatry in the treatment of violent patients.

During the past 2 decades psychiatry has made great progress in describing patterns of violence by psychiatric patients and developing standards for the evaluation and treatment of these patients. Studies have found that roughly 10% of patients were violent toward other persons just prior to psychiatric hospitalization. Young male patients and patients in certain diagnostic groups had higher rates of violence. This report describes the proper evaluation of violent patients and proposes a model for the short-term potential of violent behavior. Psychiatry has developed guidelines for the acute treatment of violent patients using verbal intervention, physical restraint, and emergency medication. Long-term treatment relies on medication for the underlying disorder. Beyond their traditional indications, carbamazepine, propranolol hydrochloride, and lithium carbonate may be effective in diminishing violence. Some violent patients respond to long-term psychotherapy.

Assault, suicide, and mental illness.

The characteristics of 9,365 patients admitted to public hospitals in a one-year period were analyzed in relation to the presence of assaultive or suicidal problems prior to admission. There were definite differences in the occurrence of assaultive or suicidal problems in relation to sex, age, primary diagnosis, education, race, marital status, prior private care, and source of referral to the hospital. There were no significant differences in regard to the history of previous psychiatric admissions, veteran status, or history of seizures. These findings demonstrate the usefulness of a large, routinely collected data base in the study of specific psychiatric problems and offer directions for intervention and future research in the field of life-threatening behavior.

The effect of access to lethal methods of injury on suicide rates.

The relationship between the availability of lethal methods of injury and suicide rates is an important, but unresolved question. We investigated this relationship by prospectively classifying lethal methods according to their accessibility in the five counties of New York City. These counties have both similarities and differences in the proportion of their populations with access to specific lethal means. We then compared the age- and gender-adjusted method-specific suicide rates of these counties. There were marked differences in overall crude suicide rates among the five counties. The counties had similar suicide rates involving methods that were equally accessible to all persons in each county (eg, hanging, laceration, suffocation, and burns) as well as methods that were accessible to a smaller, but similar proportion of the population in each county (eg, firearms and drowning in waterways). Virtually all of the differences in overall suicide risk among counties were explained by differences in rates involving methods that were differentially available in the counties, principally fall from height, overdose of prescription medications, and carbon monoxide poisoning. We conclude that differences in suicide rates between communities are, in large part, due to differences in accessibility to lethal methods of injury. Therefore, systematic studies should evaluate the effect of reducing accessibility to specific lethal means on suicide rates.

The urban built environment and overdose mortality in New York City neighborhoods.

Accidental drug overdose continues to be a substantial cause of mortality for drug users. Characteristics of the neighborhood built environment may be important determinants of the likelihood of drug overdose mortality independent of individual-level factors. Using data from the New York City Office of the Chief Medical Examiner, we conducted a multilevel case control study using data on accidental overdose deaths as cases and non-overdose accidental deaths as controls. We used archival data from the New York City Housing and Vacancy Survey and the Mayor's Office of Operations to assess characteristics of neighborhood external (e.g. dilapidation of buildings) and internal (e.g. quality of utilities in houses) built environment. Multilevel analyses were used to assess the relations between the neighborhood built environment and the likelihood of overdose death. Six out of the eight characteristics of the external environment studied and three out of the six characteristics of the internal environment studied were significantly associated with the likelihood of fatal drug overdose in multilevel models after adjusting for individual-level (age, race, sex) and neighborhood-level (income, drug use) variables. Deterioration of the built environment, particularly the external environment, is associated with an increased likelihood of fatal accidental drug overdose. Disinvestment in social resources, psychosocial stressors, neighborhood differences in response to a witnessed overdose, and differences in vulnerability to the adverse consequences of drug use in different neighborhoods may explain the observed associations.

Characteristics of assaultive patients in private hospitals.

A study of two large private psychiatric hospitals showed rates and patterns of assaultive behavior by patients comparable to those found earlier in a study of public hospitals; this was especially true in the hospital that admitted involuntary patients. The targets of assault were predominantly family members other than spouses or children and persons outside the family. Seclusion was commonly used to manage assaultive patients in the private hospitals and the seclusion rates were higher than those found for public hospitals, probably reflecting a staff preference for seclusion over heavy medication. The need for staff education and support in the management of assaultive patients exists in private hospitals as well as public hospitals.

Assaultive behavior among psychiatric outpatients.

Of 2,916 patients evaluated by psychiatric residents in the outpatient clinics of two large private psychiatric hospitals, 3% had manifested recent assaultive behavior toward other persons. In over half the cases the target of assault was a family member other than a child. Patients more likely to be assaultive were young and male and had a diagnosis of childhood or adolescent disorder or personality disorder. The authors compare these results with those from studies of assault among inpatients and recommend that physicians in outpatient as well as inpatient settings be familiar with the management of assaultive patients.

Increase in fatal suicidal poisonings and suffocations in the year Final Exit was published: a national study.

Final Exit was a best-selling book that recommended poisoning and suffocation by plastic bag as lethal means of suicide for those with terminal medical illnesses. The authors sought to determine whether the number of suicides involving these methods increased in the United States in 1991, the year the book was published, compared with 1990. Suicidal asphyxiations involving a plastic bag increased 30.8%, from 334 to 437, and poisonings increased 5.4%, from 3,143 to 3,314. There was no change in the number of suicides involving each of the other methods or in the total number of suicides between 1990 and 1991. These ecological data support, but cannot conclusively prove, the hypothesis that Final Exit influenced the choice of lethal means of suicidal individuals.

Low serum cholesterol level and attempted suicide.

OBJECTIVE: Several studies suggest that a low cholesterol concentration is associated with a greater than normal risk of mortality from suicide. The authors sought to determine whether a low cholesterol level is associated with a history of serious suicide attempts among psychiatric inpatients. METHOD: Lifetime history of attempted suicide of 650 patients, aged 18-59 years, consecutively admitted to a psychiatric hospital was assessed by semistructured interview. The seriousness of an attempt was rated on the basis of the resulting medical injury. Serum cholesterol levels, obtained from the admission biochemical profiles, were divided into quartiles. RESULTS: Compared to men with low cholesterol levels (defined as less than or equal to the 25th percentile), men with cholesterol levels above the 25th percentile were less likely to have ever made a serious suicide attempt when age, weight, race, socioeconomic status, alcohol use, and depression were controlled for. There was no association between cholesterol level and attempted suicide in women. CONCLUSIONS: Male psychiatric patients with low cholesterol levels were twice as likely to have ever made a medically serious suicide attempt than men with cholesterol levels above the 25th percentile. Low cholesterol concentration should be further investigated as a potential biological marker of suicide risk.

Prevalence of cocaine use among residents of New York City who committed suicide during a one-year period.

OBJECTIVE: In the mid-1980s the form of cocaine called "crack" became widely available in New York City. The authors sought to determine the prevalence of cocaine metabolites detected at autopsy in persons who committed suicide in New York City during this period. METHOD: Individual reviews of the autopsy and toxicological records of all persons under the age of 61 who had committed suicide in the city during a 1-year period were conducted to determine demographic characteristics, suicide methods, and cocaine and alcohol use at the time of death. RESULTS: In one of every five cases studied, the person who committed suicide had used cocaine within days of his or her death. The prevalence of cocaine use among young Hispanic males who committed suicide was 45%. Persons who were young, black, or Hispanic and who had used alcohol immediately before the fatal injury were most likely to have been recent cocaine users. After controlling for demographic variables and ethanol use, the investigators found that individuals who committed suicide with firearms were twice as likely to have used cocaine as those who used other methods. CONCLUSIONS: In contrast to the results of regional and household surveys during this period, which suggested that the current prevalence of cocaine use in New York City was 3%-5%, these results suggest a high prevalence of cocaine use in the days immediately preceding death by young persons who commit suicide. Additional studies are needed to determine how cocaine may act as a risk factor for suicide.

Violence by patients admitted to a private psychiatric hospital.

OBJECTIVE: The authors determined the rates and patterns of violence toward persons by psychiatric patients before admission to the inpatient service of the Payne Whitney Clinic and determined which factors were associated with a greater risk of violence. METHOD: During hospitalization, 763 patients were interviewed by a research assistant using a structured interview instrument. The interviewer inquired about demographic and socioeconomic information and about history of violence and alcohol and drug use. RESULTS: Having physically attacked another person in the month before admission was equally likely among male (13.6%) and female (14.7%) patients. The patterns of violence were similar for men and women in terms of target, severity of injuries, use of a weapon, and place of occurrence. Univariate analyses showed that only youth was associated with violence for male patients, while youth, low socioeconomic status, substance abuse, and axis II pathology were associated with a greater risk of violence for female patients. Logistic regression analyses showed that recent cocaine use was significantly associated with violence by female patients when age, socioeconomic status, and axis II pathology were controlled for. For male patients, recent heroin use was related to a greater risk of violence. CONCLUSIONS: The frequency of violence by female patients was 150% higher than it was in a study at the Payne Whitney Clinic a decade ago. The frequency of violence by male patients was 50% higher than it was a decade ago. In the current study, substance abuse was associated with greater risk of violence by patients.

Use of prescription psychotropic drugs among suicide victims in New York City.

OBJECTIVE: The authors examined the rate of prescription psychotropic drug use among suicide victims at the time of their death. METHOD: From a total of 1,970 suicides that occurred in New York City from 1990 to 1992, 1,635 cases that had a complete toxicologic analysis and an injury-death interval of 48 hours or less were assessed at autopsy for the presence of commonly prescribed antidepressants and neuroleptics. RESULTS: Prescription psychotropic medications were detected in only 16.4% (N = 268) of the suicide victims studied. Demographic factors associated with use of these drugs included female gender and white race. Poisoning accounted for 17.9% (N = 293) of all suicides studied, but antidepressants or neuroleptics were detected in less than half of these victims. Among all suicide victims in whom an antidepressant or neuroleptic was detected, almost half had used lethal methods other than poisoning. CONCLUSIONS: In this study, most individuals who committed suicide in New York City were not taking prescription psychotropic medications at the time of their death and either were not receiving pharmacotherapy or were noncompliant.

Lower risk of suicide during pregnancy.

OBJECTIVE: The authors determined the risk of suicide during pregnancy. METHOD: The autopsy reports of all female residents of New York City, 10-44 years old, who committed suicide from 1990 to 1993 were assessed for pregnancy. These data were compared with age-adjusted and race-adjusted standardized mortality ratios for women, which were calculated by using population data from the 1990 U.S. Census as well as data obtained from the New York City Health Department on the number of live births, spontaneous abortions, and induced abortions. RESULTS: The standardized mortality ratio for suicide during pregnancy was 0.33; that is, the number of suicides of pregnant women was only one-third of that expected. CONCLUSIONS: Despite the mood swings and stresses associated with pregnancy and impending childbirth, pregnant women have a significantly lower risk of suicide than women of childbearing age who are not pregnant.

HIV seroprevalence among suicide victims in New York City, 1991-1993.

OBJECTIVE: The authors sought to determine the HIV seroprevalence among suicide victims in New York City. METHOD: All suicides of city residents from 1991 through 1993 were studied. The crude proportion of all suicide victims who were HIV positive and the proportion adjusted to the age, gender, and racial/ethnic characteristics of the New York City population were determined. The demographically adjusted proportion was then contrasted with HIV seroprevalence estimates for the New York City general population. HIV-seropositive suicide victims were assessed for pathological findings suggestive of HIV-related illnesses. RESULTS: The crude proportion of all suicide victims who were HIV seropositive was 0.088, and the demographically adjusted proportion was 0.049. Over 90% of all HIV-positive suicide victims were aged 25 to 54 years, and almost 90% were men. Among black and Hispanic men aged 35 to 54 years who committed suicide, the proportion who were HIV seropositive was 0.252--the highest seropositive rate of any demographic group. More than two-thirds of HIV-seropositive suicide victims had no HIV-related pathology or AIDS-indicator conditions at autopsy. CONCLUSIONS: The demographically adjusted proportion of suicide victims who were HIV positive (approximately 0.038 to 0.059), contrasted with the HIV seroprevalence estimates for the New York City general population (approximately 0.014 to 0.032), the absence of HIV-related pathology among suicide victims, and the likelihood that many HIV-positive individuals had other risk factors for suicide, such as substance abuse, suggests that a positive HIV serostatus is associated, at most, with a modest elevation in suicide risk.

HIV infection among victims of accidental fatal drug overdoses in New York City.

AIMS: To determine the factors associated with HIV seroprevalence rates for victims of drug overdoses. DESIGN: Descriptive epidemiologic survey of a complete 3-year sample of accidental fatal drug overdoses. SETTING: New York City (population 7,322,564). PARTICIPANTS: All people over 15 years of age (n = 2159) who died of accidental fatal drug overdoses during 1991-93. MEASUREMENTS: Using medical examiner data and logistic regression analyses were conducted to examine the association between HIV seroprevalence and gender, race, age and type of drug overdose. FINDINGS: There were 646 (29.9%) victims who were HIV positive. Women (37.5%) were more likely than men (27.9%) to be HIV positive. African-Americans (39.4%) had a higher rate of HIV infection than Latinos (27.5%), whites (19.2%) or Asians (8.3%). Victims residing in communities with higher levels of poverty had higher rates of HIV infection but poverty did not account for the high rates of HIV infection among African-Americans. The highest rates of HIV infection were found among victims aged 35-44 years (38.8%) and 45-54 years (33.7%). Dying from an opiate overdose was associated with a 2.4 times increase in the likelihood of being HIV positive. CONCLUSION: If opiate abuse continues to rise in the United States, HIV infection will increase in the next few years. Women who abuse drugs participate in risky sexual practices and are more likely than men to develop HIV infection from receptive sex as well as sharing of needles. Harm reduction programs should address risky sex as well as needle programs. There should be further study of why African-Americans who died of drug overdoses have the highest rates of HIV infection.

Overdose deaths attributed to methadone and heroin in New York City, 1990-1998.

AIMS: Methadone treatment has been shown to be an effective intervention that can lower the risk of heroin-induced overdose death. Recent reports have suggested increases in methadone-induced overdose deaths in several locations in the USA and in Europe. This study investigated the role of methadone and opiates in accidental overdose deaths in New York City. DESIGN: We analysed data from the Office of the Chief Medical Examiner to examine all accidental drug overdose deaths in New York City between 1990 and 1998. FINDINGS: Of 7451 total overdose deaths during this period, there were 1024 methadone-induced overdose deaths, 4627 heroin-induced overdose deaths and 408 overdose deaths attributed to both methadone and heroin. Fewer than a third as many accidental overdose deaths were attributed to methadone than were attributed to heroin during this period. The proportion of accidental overdose deaths attributed to methadone did not change appreciably (12.6-15.8% of total overdose mortality), while the proportion of overdose deaths attributed to heroin increased significantly (53.5-64.2%) during the period of study. CONCLUSIONS: There was no appreciable increase in methadone-induced overdose mortality in New York City during the 1990s. Both heroin-induced overdose mortality and prescriptions of methadone increased during the same interval.

Management of the violent patient in an emergency situation.

The management of an acute episode of violence by a psychiatric patient is probably one of the most demanding actions in psychiatry in terms of clinical competence and emotional impact on the clinician. In such situations, consideration of the safety of staff and other patients is paramount. Interventions available to the clinician in the management of acute violence include verbal intervention, restraint, seclusion and medication. This article offers guidelines for how to communicate with the patient. Issues of countertransference and emotional reactions to patients are addressed. The author has worked to develop national guidelines for the psychiatric use of seclusion and restraint in terms of indications, contraindications, implementation, review by the physician and the monitoring and care of the patient by staff.

Mentally abnormal offenders. Evaluation and management of violence.

Over the past two decades, much has been learned about the evaluation and management of violent patients. This has been translated into clinical guidelines for the evaluation and management of violent persons with psychiatric disorders. New research on neurotransmitters and the use of technology that can explore neurophysiologic and chemical activity in the brain promises continued advances in this area of psychiatry.

Unusual diagnoses among violent patients.

Several medical disorders rarely cause violent behavior. When they do so, it is dramatic because the violence and other bizarre behaviors are not in keeping with the premorbid picture of the individual. Often, medical and neurologic symptoms are present, but occasionally psychiatric symptoms may present alone with the aggression and violence, which points out the importance of complete medical psychiatric evaluations of patients who present with recent histories of violent behavior. Most violence involves "horses," but the rare "zebras" should be kept in mind because they are often treatable.

A profile of homicides on the streets and in the homes of New York City.

Although prior research has found that homes containing firearms and illicit drug and ethanol users are more likely to be the scene of a homicide than homes that do not contain these elements, the authors studied homicides on the streets as well as in homes so as to assess the role of firearms, cocaine, and ethanol in both settings. Using the files of the Chief Medical Examiner, the authors reviewed all 4,468 homicides occurring in New York City in 1990 and 1991. The most frequent places of occurrence were the streets and other outdoor places (49.6 percent) and the victims' homes (19.3 percent). Firearms were the cause of death for 49.6 percent of homicides in the home and 80.3 percent of those on the streets. Use of cocaine and ethanol was found more frequently among victims killed on the streets than those killed at home. In addition, victims killed on the streets were more likely to be male, ages 15-24 years, and African American. Further research in regard to prevention and intervention strategies is needed, keeping in mind the different patterns of homicide on the streets compared with those occurring in other settings.

A prospective study of violence by psychiatric patients after hospital discharge.

OBJECTIVE: The study assessed the frequency of violence by patients two weeks after discharge from a psychiatric hospital and identified characteristics of patients with an increased risk of violence after discharge. METHODS: A structured form was used to interview patients aged 18 to 59 years in a private university psychiatric hospital. Patients provided self-reports of past violence, and violence while in the hospital was assessed by routine nurse ratings. Patients were telephoned two weeks after discharge to assess violence since discharge. RESULTS: Sixteen of 430 patients who were interviewed by telephone two weeks after discharge reported violence against persons since their discharge. Patients who were violent in the month before admission were nine times more likely to be violent in the two weeks after discharge, compared with patients who were not violent just before admission. Patients with a personality disorder were four times more likely than patients without a personality disorder to be violent after discharge. The targets of violence were often family members or other intimates and often the same persons attacked before hospitalization. CONCLUSIONS: Patients who were violent just before admission were more likely to be violent after discharge and to attack the same persons they had attacked in the past. Clinicians should routinely evaluate past violence and work with the patient and potential targets of violence to prevent future violence.