Rapid tranquilization of severely agitated patients with schizophrenia spectrum disorders: a naturalistic, rater-blinded, randomized, controlled study with oral haloperidol, risperidone, and olanzapine.

INTRODUCTION: Agitation is a major problem in acute schizophrenia. Only a few studies have tested antipsychotic agents in severely agitated patients, mainly because of legal issues. Furthermore, most studies were limited to the first 24 hours. We aimed to investigate the efficacy of oral haloperidol, risperidone, and olanzapine in reducing psychotic agitation in severely agitated patients with schizophrenia or schizophreniform or schizoaffective disorder over 96 hours using a prospective, randomized, rater-blinded, controlled design within a naturalistic treatment regimen. METHODS: In total, 43 severely agitated patients at acute care psychiatric units were enrolled. Participants were randomly assigned to receive either daily haloperidol 15 mg, olanzapine 20 mg, or risperidone 2 to 6 mg over 5 days. Positive and Negative Syndrome Scale psychotic agitation subscale score was the primary outcome variable. A mixed-model analysis was applied. RESULTS: All drugs were effective for rapid tranquilization within 2 hours. Over 5 days, the course differed between agents (P < 0.001), but none was superior. Dropouts occurred only in the risperidone and olanzapine groups. Men responded better to treatment than did women during the initial 2 hours (P = 0.046) as well as over the 5-day course (P < 0.001). No difference between drug groups was observed regarding diazepam or biperiden use. CONCLUSIONS: Oral haloperidol, risperidone, and olanzapine seem to be suitable for treating acute severe psychotic agitation in schizophrenia spectrum disorders. Response to oral antipsychotics demonstrated a gender effect with poorer outcome in women throughout the study.

Procedures for preventing juvenile violence in Switzerland: the Zurich model.

The Swiss legal system places strong emphasis on risk assessment and treatment of potentially violent offenders. Especially after the 2001 Zug massacre, there is close cooperation between the judicial and mental health systems to prevent violence through early detection and intervention. A case study of a risk management program for a dangerous seventeen-year-old delinquent youth illustrates this approach.

Neurobiological determinism: human freedom of choice and criminal responsibility.

Several authors have argued that criminal behavior is generally caused by neurobiological deficits. This assumption not only questions the concept of free will and a person's responsibility for his or her own actions but also the principle of guilt in criminal law. When critically examining the current state of research, it becomes apparent that the results are not sufficient to support the existence of a universally valid neurobiological causality of criminal behavior. Moreover, the assumption of total neurobiological determination of human behavior and the impossibility of individual responsibility are characterized by both faulty empiricism and methodical misconceptions. The principle of relative determinism and the analysis of the offender's behavior at the time of the offense thus remain the central and cogent approach to the assessment of criminal responsibility.

Risk assessment instruments in repeat offending: the usefulness of FOTRES.

Research in the area of predicting recidivism has produced several well-validated standardized risk assessment instruments. The question arises, which instruments best serve which purposes? The objective of this study was to evaluate and compare several actuarial and dynamic risk assessment instruments as to their predictive accuracy and their usefulness in forensic practice. The sample consisted of 109 violent and sex offenders who had been released from prison in Switzerland between 1994 and 1999, and for whom the Psychopathy Checklist-Revised (PCL-R); Historical, Clinical, Risk Management-20; Level of Service Inventory-Revised; Violence Risk Appraisal Guide (VRAG); and the Swiss assessment instrument FOTRES were scored. Using bivariate logistic regression analyses, all instruments were able to discriminate between recidivists and nonrecidivists. The receiver operating characteristic analyses yielded area under the curve values between 0.70 (VRAG) and 0.84 (PCL-R). Furthermore, it was shown that solely examining AUC values does not suffice to determine usefulness. A comprehensive evaluation of an instrument's usefulness for forensic practice should also look at qualitative criteria such as area of application, specificity of risk assessed, and inclusion of dynamic items among others.