Exposure to violence in childhood and risk of violence in adult schizophrenia: Results from a multinational study.

This study investigated the connection between childhood violence exposure and violent behavior in adults with schizophrenia spectrum disorders (SSDs). The case-control study included 398 SSD patients: 221 cases with a history of severe interpersonal violence in the past and 177 controls with no history of violence. The findings indicated that cases were significantly more likely to report childhood exposure to all forms of witnessed or personally sustained violence both within and outside the family, with those who had witnessed intra-familial violence being more likely to assault a family member in adulthood. Cases reported exposure to violence before the age of 12 years significantly more frequently than controls, and those with early-life violence exposure were significantly more likely to report that they were in a state of intense anger when they behaved violently. A dose-response relationship was observed, with evidence of an increased risk of later violence when the exposure occurred before the age of 12 and an increased likelihood of intrafamilial violence. The evidence suggests that childhood violence exposure was associated with an increased risk of violent behavior in adult SSD patients, and early exposure was linked to an increased likelihood of physical violence occurring in states of intense anger.

Characteristics of people attending psychiatric clinics in inner Sydney homeless hostels.

OBJECTIVE: To describe the characteristics of people attending mental health clinics at shelters for the homeless in inner city Sydney. DESIGN: Retrospective review of medical records of homeless hostel clinic attenders. SETTING: Mental health clinics located in three inner city homeless hostels. PARTICIPANTS: Consecutive series of clinic attenders, 21 July 2008 - 31 December 2016. MAIN OUTCOME MEASURES: Demographic characteristics; social, medical and mental health histories of homeless people. RESULTS: 2388 individual patients were seen at the clinics during the 8.5-year study period. Their mean age was 42 years (standard deviation, 13 years), 93% were men, and 56% were receiving disability support pensions. 59% of attenders had been homeless for more than a year, and 34% of all attenders reported sleeping in the open. The most common diagnoses were substance use disorder (66%), psychotic illness (51%), acquired brain injury (14%), and intellectual disability (5%). Most patients had more than one diagnosis. Early life and recent trauma was reported by 42% of patients. Pathways to homelessness included release from prison (28% of the homeless), discharge from a psychiatric hospital (21%), loss of public housing tenancy (21%), and inability to pay rent because of problem gambling. CONCLUSIONS: The high rates of substance use and mental disorder among homeless people in inner Sydney confirms the need for increased access to treatment for these conditions in this setting. Homelessness among those with mental illness might be reduced by developing alternative housing models, and supporting people with multiple problems to retain tenancy.

The first 30 months of the MindSpot Clinic: Evaluation of a national e-mental health service against project objectives.

OBJECTIVE: The MindSpot Clinic provides online mental health services to Australian adults with anxiety and depression. This paper describes users of MindSpot between January 2013 and June 2015. Outcomes are considered against three key objectives: improving access to mental health services, improving public awareness of how to access services and providing evidence-based treatments. METHOD: Website traffic data were examined to determine patterns of use. Demographic characteristics, past service utilisation and reasons for contacting MindSpot were analysed. Outcomes for patients enrolled in a MindSpot treatment course were also analysed. Primary outcomes were scores on the 9-Item Patient Health Questionnaire, Generalised Anxiety Disorder 7-Item, Yale-Brown Obsessive Compulsive Scale and Post-Traumatic Stress Disorder Checklist-Civilian Version, administered at assessment, post-treatment and 3-month follow-up. RESULTS: The website was visited by almost 500,000 Australians, of which 33,990 adults started assessments, and 25,469 people completed assessment and were eligible for analysis. Mean age was 36.4 years (standard deviation = 13.3 years; range = 18-94 years), and 72% were female. The proportion living in rural or remote regions and who identified as Aboriginal and Torres Strait Islander closely matched national statistics. The majority (82%) reported that they were not currently in contact with mental health services. Most patients sought an assessment, information about treatment options, or referral to another service, and only 24% of those completing an assessment commenced a MindSpot treatment course. Of these, large clinical effects ( d: 0.7-2.4; average symptom reductions: 25.5% to 61.6%) were found from assessment to follow-up on all outcome measures. Deterioration ranged from 1.0% to 4.3%. CONCLUSION: Based on the number of website visits, completed assessments and treatment outcomes, MindSpot achieved its three programme objectives. This model of service provision has considerable value as a complement to existing services, and is proving particularly important for improving access for people not using existing services.

MindSpot Clinic: An Accessible, Efficient, and Effective Online Treatment Service for Anxiety and Depression.

OBJECTIVE: The main objective of this study was to report the feasibility of delivering online cognitive-behavioral therapy (iCBT) treatments for anxiety and depression in a national public mental health service. METHODS: A prospective noncontrolled cohort study was conducted of all patients who began assessment or treatment at the MindSpot Clinic from January through December 2013. Clinic services were used by a representative cross-section of the Australian population. Mean age at assessment was 36.4±13.0 years, and age range was 18-86 years. Patients completed one of four online courses over eight weeks, during which they received weekly support from a therapist via telephone or secure e-mail. Primary outcome measures were the nine-item Patient Health Questionnaire (PHQ-9) and the seven-item Generalized Anxiety Disorder scale (GAD-7) administered at posttreatment and three months posttreatment. RESULTS: A total of 10,293 adults who self-identified as having problems with anxiety or depression commenced assessment, and 7,172 completed the assessment and were eligible for analysis. Of these, 2,049 enrolled in a course and 1,471 completed the course, for a course completion rate of 71.8%. Moderate to large noncontrolled effect sizes (Cohen's d=.67-1.66, 95% confidence interval=.08-2.07) were found from assessment to three-month follow-up. At posttreatment and follow-up, reliable recovery ranged from 46.7% to 51.1%, and deterioration ranged from 1.9% to 3.8%. Mean total therapist time per patient was 111.8±61.6 minutes. CONCLUSIONS: The MindSpot Clinic produced treatment outcomes that were comparable to results from published clinical trials of iCBT. This model of service delivery represents an innovative method of providing accessible, low-cost, effective, and acceptable mental health services to many people who currently are not receiving care.

A 21-year retrospective outcome study of New South Wales forensic patients granted conditional and unconditional release.

AIM: To retrospectively examine the outcomes of forensic patients found not guilty by reason of mental illness (NGMI) in New South Wales (NSW) and subsequently released into the community, as measured by reoffending, conditional release revocation and psychiatric hospital readmission. METHOD: Data were collected from the NSW Mental Health Review Tribunal (MHRT) files for all patients who received an NGMI verdict between January 1990 and December 2010, and who were released into the community during this period. The outcome measures of conditional release revocation and psychiatric hospital readmission were extracted from these files. Information about subsequent criminal charges, convictions and penalties were obtained from the Bureau of Crime Statistics and Research's reoffending database. RESULTS: During the 21-year period studied, 364 offenders received an NGMI verdict and were placed under the supervision of the MHRT. Of these, 197 were released into the community, including 85 who were granted unconditional release. Over a follow-up period averaging 8.4 years, 18% of conditionally released patients reoffended, 11.8% were convicted of a further offence, 8.7% were charged with a violent offence, 3.1% were convicted of a violent offence and 3.7% were sentenced to a term of imprisonment. Five (3.1%) conditionally released forensic patients received a further NGMI verdict. One-quarter of the conditionally released patients had their conditional release revoked and half were readmitted to hospital. Of the forensic patients granted unconditional release, 12.5% were charged with an offence, 9.4% received convictions for an offence, 6.3% were charged with a violent offence and 4.7% were convicted of a violent offence, in a mean follow-up period of 7.6 years. None committed a further serious offence resulting in a term of imprisonment, nor a second NGMI verdict. CONCLUSIONS: The results of this study suggest that the treatment and rehabilitation of forensic patients in NSW, together with the decision-making procedures of the MHRT, is effective in protecting the community from further offending by forensic patients.

Overview of violence to self and others during the first episode of psychosis.

BACKGROUND: We aimed to review the evidence for an association between the first episode of psychosis and violence and to consider the possible explanations for this association and the implications for clinicians and service providers. DATA SOURCES: We searched for published studies in English describing an association between violence and first-episode psychosis using the subject headings, key words, abstracts, and titles in PubMed/MEDLINE from 1970 to 2010, using the terms first-episode schizophrenia OR first-episode psychosis OR early schizophrenia AND suicide OR self harm OR suicide attempt OR homicide OR violence. STUDY SELECTION: We identified 20 studies reporting data on violent suicide attempts, self-mutilation, minor violence, severe nonlethal interpersonal violence, or homicide in first-episode and previously treated psychosis. DATA EXTRACTION: The number of people committing acts of violence prior to initial treatment for psychosis and after initial treatment was extracted from the relevant studies. RESULTS: The proportion of people found to be in the first episode of psychosis at the time of an act of violence was compared to the expected ratio of first-episode to previously treated patients. A substantial proportion of psychotic patients examined after violent suicide attempts (49%), major self-mutilation (54%), homicide (39%), and assault resulting in serious injury (38%) are in their first episode of psychosis. Moreover, a substantial proportion of first-episode patients commit an act of less serious violence or attempt suicide prior to initial treatment. CONCLUSIONS: The findings support the need for early intervention and community-wide programs to reduce the duration of untreated psychosis.

Mania, homicide and severe violence.

BACKGROUND: Mania has been reported to be a risk factor for aggression and violence in psychiatric hospitals, but the extent of any association between mania and severe interpersonal violence in community settings is not known. AIM: To examine the association between mania and severe violence in a series of patients found not guilty by reason of mental illness (NGMI). METHODS: A review of the court documents of those found NGMI of offences involving severe violence, including homicide, attempted homicide and assault causing wounding or serious injury, in New South Wales between 1992 and 2008. RESULTS: Twelve of 272 people found NGMI were in a manic state when they committed a severe violence offence. Ten were diagnosed with schizo-affective disorder and two with bipolar disorder. Three patients were in the depressed phase of schizo-affective disorder and there were no patients in the depressed phase of bipolar disorder. CONCLUSION: Mania, in particular the manic phase of bipolar disorder, is not strongly associated with severe violence.

Self-enucleation: forget Freud and Oedipus, it's all about untreated psychosis.

Self-enucleation is a rare but serious ophthalmological and psychiatric emergency. It has traditionally been considered to be the result of psycho-sexual conflicts, including those arising from Freud's Oedipal complex and Christian religious teaching. However, an analysis of published case reports suggests that self-enucleation is a result of psychotic illnesses such as schizophrenia. Early treatment with antipsychotic medication in the case of unilateral or threatened self-enucleation might prevent some cases of blindness.

Meta-analysis of self-reported substance use compared with laboratory substance assay in general adult mental health settings.

An accurate assessment of substance use is necessary to make a correct psychiatric diagnosis and to provide appropriate treatment. This study uses meta-analysis to establish the strength of the association between self-reported substance use and the results of laboratory substance assay including the testing for specific substances and screening for any substance use in psychiatric hospitals and in community mental health settings. A systematic search for published studies was supplemented by additional data required for meta-analysis provided by several researchers in this field. Using random-effects meta-analysis, we calculated the pooled estimate of the odds ratio of a positive substance assay in patients reporting use or non-use of substances and estimated the sensitivity, specificity, positive predictive value and negative predictive value. Twenty-six studies met the inclusion criteria. Very strong associations were found between self-reported use and positive tests for cannabis [N = 11 studies, odds ratio (OR) = 22.3; 95% confidence interval (CI) = 10.1-49.1], amphetamines (N = 8, OR = 26.6; 95% CI = 7.9-88.9), cocaine (N = 8, OR = 39.7; 95% CI = 16.2-97.2) and opiates (N = 7, OR = 83.5; 95% CI = 26.7-260.7). Strong associations were found between self-reported use of any substance and positive substance screening (N = 15, OR = 7.2, 95% CI = 3.6-14.1) and tests for alcohol use (N = 5, OR = 8.5; 95% CI = 2.5-28.4). Screening for any substance use had a sensitivity of 61% and a specificity of 66%. Testing for individual substances was specific but lacked sensitivity. Screening has the potential to detect clinically relevant substances that would not be reported by the patient, whereas testing for a specific substance has little advantage over self-report. The sensitivity of the substance assay might be improved by obtaining a sample at the earliest opportunity. Consideration should be given to the increased use of substance screening in general adult mental health settings because it could improve the accuracy of psychiatric diagnosis and increase the likelihood of patients receiving treatment for substance use disorders.

Comparison of first-episode and previously treated persons with psychosis found NGMI for a violent offense.

OBJECTIVE: Evidence has emerged of a higher risk of serious violence in first-episode psychosis. This study compared the characteristics of two groups of persons with psychosis found not guilty of violent offenses on the grounds of mental illness (NGMI): those who had not yet been treated and those who had previously received treatment. METHODS: Demographic, clinical, and offense data were taken from psychiatric reports and court documents for persons found NGMI of homicide, attempted homicide, and assaults causing serious injury in the state of New South Wales, Australia. RESULTS: Between 1992 and 2008, 272 persons were found NGMI of homicide (N=138) or attempted homicide and assault resulting in serious injury (N=134). Schizophrenia-related psychosis was the most common diagnosis (N=234, 86%); 93 (34%) had a co-occurring substance use disorder. Of the 272 offenders, 124 (46%) were classified as being in their first episode of psychosis, including 72 (52%) of the homicide offenders and 52 (39%) of those who committed a nonlethal violent offense. Multiple logistic regression analysis found that compared with those who had received previous treatment for psychosis, the first-episode patients were younger, more likely to be from a non-English-speaking country, and more likely to have used a firearm in the offense. CONCLUSIONS: The first episode of psychosis is a period of particular risk for homicide and serious violence. Younger age, language and cultural barriers to care, and greater availability of lethal means appear to contribute to an increased risk of homicide and of other serious violent offenses in first-episode psychosis.