Psychological interventions for antisocial personality disorder.

BACKGROUND: Antisocial personality disorder (AsPD) is associated with poor mental health, criminality, substance use and relationship difficulties. This review updates Gibbon 2010 (previous version of the review). OBJECTIVES: To evaluate the potential benefits and adverse effects of psychological interventions for adults with AsPD. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, 13 other databases and two trials registers up to 5 September 2019. We also searched reference lists and contacted study authors to identify studies. SELECTION CRITERIA: Randomised controlled trials of adults, where participants with an AsPD or dissocial personality disorder diagnosis comprised at least 75% of the sample randomly allocated to receive a psychological intervention, treatment-as-usual (TAU), waiting list or no treatment. The primary outcomes were aggression, reconviction, global state/functioning, social functioning and adverse events. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. MAIN RESULTS: This review includes 19 studies (eight new to this update), comparing a psychological intervention against TAU (also called 'standard Maintenance'(SM) in some studies). Eight of the 18 psychological interventions reported data on our primary outcomes. Four studies focussed exclusively on participants with AsPD, and 15 on subgroups of participants with AsPD. Data were available from only 10 studies involving 605 participants. Eight studies were conducted in the UK and North America, and one each in Iran, Denmark and the Netherlands. Study duration ranged from 4 to 156 weeks (median = 26 weeks). Most participants (75%) were male; the mean age was 35.5 years. Eleven studies (58%) were funded by research councils. Risk of bias was high for 13% of criteria, unclear for 54% and low for 33%. Cognitive behaviour therapy (CBT) + TAU versus TAU One study (52 participants) found no evidence of a difference between CBT + TAU and TAU for physical aggression (odds ratio (OR) 0.92, 95% CI 0.28 to 3.07; low-certainty evidence) for outpatients at 12 months post-intervention. One study (39 participants) found no evidence of a difference between CBT + TAU and TAU for social functioning (mean difference (MD) -1.60 points, 95% CI -5.21 to 2.01; very low-certainty evidence), measured by the Social Functioning Questionnaire (SFQ; range = 0-24), for outpatients at 12 months post-intervention. Impulsive lifestyle counselling (ILC) + TAU versus TAU One study (118 participants) found no evidence of a difference between ILC + TAU and TAU for trait aggression (assessed with Buss-Perry Aggression Questionnaire-Short Form) for outpatients at nine months (MD 0.07, CI -0.35 to 0.49; very low-certainty evidence). One study (142 participants) found no evidence of a difference between ILC + TAU and TAU alone for the adverse event of death (OR 0.40, 95% CI 0.04 to 4.54; very low-certainty evidence) or incarceration (OR 0.70, 95% CI 0.27 to 1.86; very low-certainty evidence) for outpatients between three and nine months follow-up. Contingency management (CM) + SM versus SM One study (83 participants) found evidence that, compared to SM alone, CM + SM may improve social functioning measured by family/social scores on the Addiction Severity Index (ASI; range = 0 (no problems) to 1 (severe problems); MD -0.08, 95% CI -0.14 to -0.02; low-certainty evidence) for outpatients at six months. 'Driving whilst intoxicated' programme (DWI) + incarceration versus incarceration One study (52 participants) found no evidence of a difference between DWI + incarceration and incarceration alone on reconviction rates (hazard ratio 0.56, CI -0.19 to 1.31; very low-certainty evidence) for prisoner participants at 24 months. Schema therapy (ST) versus TAU One study (30 participants in a secure psychiatric hospital, 87% had AsPD diagnosis) found no evidence of a difference between ST and TAU for the number of participants who were reconvicted (OR 2.81, 95% CI 0.11 to 74.56, P = 0.54) at three years. The same study found that ST may be more likely to improve social functioning (assessed by the mean number of days until patients gain unsupervised leave (MD -137.33, 95% CI -271.31 to -3.35) compared to TAU, and no evidence of a difference between the groups for overall adverse events, classified as the number of people experiencing a global negative outcome over a three-year period (OR 0.42, 95% CI 0.08 to 2.19). The certainty of the evidence for all outcomes was very low. Social problem-solving (SPS) + psychoeducation (PE) versus TAU One study (17 participants) found no evidence of a difference between SPS + PE and TAU for participants' level of social functioning (MD -1.60 points, 95% CI -5.43 to 2.23; very low-certainty evidence) assessed with the SFQ at six months post-intervention. Dialectical behaviour therapy versus TAU One study (skewed data, 14 participants) provided very low-certainty, narrative evidence that DBT may reduce the number of self-harm days for outpatients at two months post-intervention compared to TAU. Psychosocial risk management (PSRM; 'Resettle') versus TAU One study (skewed data, 35 participants) found no evidence of a difference between PSRM and TAU for a number of officially recorded offences at one year after release from prison. It also found no evidence of difference between the PSRM and TAU for the adverse event of death during the study period (OR 0.89, 95% CI 0.05 to 14.83, P = 0.94, 72 participants (90% had AsPD), 1 study, very low-certainty evidence). AUTHORS' CONCLUSIONS: There is very limited evidence available on psychological interventions for adults with AsPD. Few interventions addressed the primary outcomes of this review and, of the eight that did, only three (CM + SM, ST and DBT) showed evidence that the intervention may be more effective than the control condition. No intervention reported compelling evidence of change in antisocial behaviour. Overall, the certainty of the evidence was low or very low, meaning that we have little confidence in the effect estimates reported. The conclusions of this update have not changed from those of the original review, despite the addition of eight new studies. This highlights the ongoing need for further methodologically rigorous studies to yield further data to guide the development and application of psychological interventions for AsPD and may suggest that a new approach is required.

Ausencia de asociación entre el nivel de letalidad y la reincidencia de los intentos de suicidio en una provincia española / Absence of association between the level of lethality and the recidivism of suicide attempts in a Spanish province

Introducción. El suicidio es un problema de salud importante en España. Examinamos la relación entre la reincidencia de los intentos y el nivel de letalidad alcanzado, y el perfil de los pacientes reincidentes que realizan intentos más letales. El objetivo es establecer los factores sociodemográficos y clínicos predictores de una mayor letalidad y reincidencia. Método. Todos los pacientes atendidos por intento suicida en un área sanitaria de 360.000 habitantes de 2009 a 2014 (N = 711) fueron valorados de forma sistemática. Comparamos las características clínicas y demográficas en función de la letalidad (leve versus moderada-severa) y la reincidencia (1-2 intentos versus > 2 intentos) usando análisis univariantes y modelos de regresión. Posteriormente, repe-timos los análisis tras distribuir la muestra en cuatro grupos en función de la presencia o ausencia de alta letalidad y/o reincidencia. Resultados. La reincidencia se asoció con la edad media (35-65 años), inactividad laboral, y los trastornos de personalidad o por uso de sustancias. La letalidad se asoció con el género masculino, edades extremas, método violento y los trastornos afectivos, pero no con la reincidencia. La coincidencia de múltiples intentos y letalidad severa en un mismo paciente parece relacionarse con el grupo de edad de 35-65 años, sexo masculino, uso de métodos violentos, trastornos mentales y la inactividad laboral. Conclusiones. Distintos factores demográficos y clínicos se asocian al riesgo de letalidad médica y de reincidencia. Nuestros resultados muestran que aquellos pacientes que repiten los intentos y realizan al menos un intento de alta letalidad, tienen mayor presencia de psicopatología, sobre todo trastornos afectivos

Introduction. Suicidal behaviour is a major health problem in Spain. The aim of this study is to examine the relationship between the recurrence of suicide attempts and the level of lethality reached, and the profile of repeaters who perform more lethal attempts. Method. All patients admitted for attempted suicide in a health area of 360,000 inhabitants from 2009 to 2014 (N = 711) were systematically assessed. We compared clinical and demographic characteristics of these patients in terms of lethality (low versus moderate-severe) and recidivism (1-2 attempts versus >2 attempts) using univariate analyses and regression models. Later, we repeated the analyses after distributing the sample into four groups depending on the presence or absence of high lethality and/or recidivism. Results. Recidivism was associated with the middle-age group (35-65 years), the lack of professional activity, and personality or substance use disorders. Lethality was associated with male gender, extreme age-groups, the use of a violent method, and affective disorders, but not with recidivism. Multiple suicide attempts and high lethality in a single patient was associated with 35-65 years age-group, male gender, violent methods, mental disorders, and inactivity. Conclusions. Different demographic and clinical factors indicate an increased risk of medical lethality and recurrence in suicidal patients. Our results show that at least some recidivist patients end up making more lethal and violent attempts with the passage of time, especially if they have psychiatric comorbidity

Antisocial personality and risks of cause-specific mortality: results from the Epidemiologic Catchment Area study with 27 years of follow-up.

PURPOSE: Little is known about the effect of antisocial personality disorder (ASPD) on the risks of cause-specific mortality in the community. This study aimed to close this gap by evaluating if ASPD increases risks of cause-specific mortality in population-based residential and institutionalized samples with 27 years of follow-up. METHODS: Data were collected in four metropolitan sites as part of the Epidemiologic Catchment Area (ECA) study during 1979-1983. Records were linked to the National Death Index through the end of 2007. Cox proportional hazards models adjusted for propensity weights and sample weights were fitted to estimate the effect of ASPD on the hazard of dying. RESULTS: 420 respondents with ASPD (median survival age 71.0 years) and 15,367 without ASPD (median survival age 84.6 years) were included in this study. Those with ASPD were more likely to die from all causes (HR = 4.46; 95% CI = 2.44-8.16), suicide (HR = 2.81; 95% CI = 1.03-7.65), malignant neoplasms (HR = 4.09; 95% CI = 2.66-6.28), chronic lower respiratory disease (HR = 5.67; 95% CI = 2.92-11.0), and human immunodeficiency virus infection (HR = 8.07; 95% CI = 2.03-32.1), but not from accidents (HR = 0.58; 95% CI = 0.17-1.93) or heart disease (HR = 1.09; 95% CI = 0.43-2.76). CONCLUSIONS: Our findings demonstrate that antisocial personality disorder is a strong predictor of all-cause mortality, and cause-specific mortality. Early identification, treatment, and prevention of ASPD are important public mental health initiatives that could reduce premature mortality among this vulnerable population.

Differences in treatment adherence, program completion, and recidivism among batterer subtypes / Diferencias en la adherencia al tratamiento, finalización del programa y recaídas entre subtipos de maltratadores

The present study aimed to cross-validate Holtzworth-Munroe and Stuart’s typology in a Spanish sample of court-referred intimate partner violence batterers. The study also analyzed the typology’s capability to predict treatment attendance, completion, and IPV recidivism two years after the treatment. The sample consisted of 210 batterers court referred to a batterer intervention program. Using cluster analysis, three batterer subtypes were identified in accordance with the original typology: family-only batterers, borderline/dysphoric, and generally violent-antisocial. The typology predicted program attendance, completion, and recidivism. Batterers from the generally violent-antisocial group attended a significantly lower number of sessions, presented the highest dropout levels, and had the highest recidivism rate followed by borderline/dysphoric and family-only batterers. These findings suggest that in order to increase the effectiveness of batterer intervention programs, batterers’ different needs and risk profiles should be taken into account (AU)

Este estudio tiene por objeto la validación cruzada de la tipología de Holtzworth-Munroe y Stuart en una muestra española de maltratadores de pareja remitidos por el tribunal. También analiza la capacidad de la tipología de predecir la asistencia al tratamiento, su finalización y las recaídas a los dos años del tratamiento. La muestra constaba de 210 maltratadores derivados por un tribunal a un programa de intervención. Mediante un análisis de clústers se descubrieron tres subtipos de maltratadores, según la tipología original: maltratadores familiares únicamente, límites/disfóricos y generalmente violentos-antisociales. La tipología predijo la asistencia al programa, su finalización y las recaídas. Los maltratadores del grupo generalmente violento-antisocial asistieron a un número de sesiones significativamente menor, mostraban el mayor grado de abandono y el mayor índice de recaídas, seguidos del grupo de límites/disfóricos y de los maltratadores familiares únicamente. Dichos resultados indican que para aumentar la eficacia de los programas de intervención con maltratadores hay que tener en consideración sus diferentes necesidades y los perfiles de riesgo (AU)

Long-term suicide risk in forensic psychiatric patients.

The objectives of this study was to describe the rate of suicide and other causes of death in first admissions to a (medium) secure forensic psychiatric facility. All 595 patients were followed up for a maximum of 20 years. Death certificates were obtained and Standardized Mortality Ratios (SMRs) were calculated. At the June 2003 census, 57 patients (9.6%) had died of whom 18 (3.0%) had committed suicide; if deaths categorized as open verdicts are included the number rises to 26 (4.4%). The SMR for death by suicide was higher for a Mental Health Act classification of Mental Illness (SMR = 3,553) compared to Psychopathic Disorder (SMR = 1,892). The risks of mortality in this population are high from any cause, particularly from suicide.

Mortality predictors in a 60-year follow-up of adolescent males: exploring delinquency, socioeconomic status, IQ, high-school drop-out status, and personality.

OBJECTIVE: To examine whether socioeconomic status (SES), high school (HS) completion, IQ, and personality traits that predict delinquency in adolescence also could explain men's delinquency-related (Dq-r) mortality risk across the life span. METHODS: Through a 60-year Social Security Death Index (SSDI) follow-up of 1812 men from Hathaway's adolescent normative Minnesota Multiphasic Personality Inventory (MMPI) sample, we examined mortality risk at various ages and at various levels of prior delinquency severity. We examined SES (using family rent level), HS completion, IQ, and MMPI indicators simultaneously as mortality predictors and tested for SES (rent level) interactions with IQ and personality. RESULTS: We ascertained 418 decedents. Dq-r mortality peaked between ages 45 years to 64 years and continued through age 75 years, with high delinquency severity showing earlier and higher mortality risk. IQ and rent level failed to explain Dq-r mortality. HS completion robustly conferred mortality protection through ages 55 years and 75 years, explained IQ and rent level-related risk, but did not fully explain Dq-r risk. Dq-r MMPI scales, Psychopathic Deviate, and Social Introversion, respectively, predicted risk for and protection from mortality by age 75 years, explaining mortality risk otherwise attributable to delinquency. Wiggins' scales also explained Dq-r mortality risk, as Authority Conflict conferred risk for and Social Maladjustment and Hypomania conferred protection from mortality by age 75 years. CONCLUSIONS: HS completion robustly predicts mortality by ages 55 years and 75 years. Dq-r personality traits predict mortality by age 75 years, accounting, in part, for Dq-r mortality.

Recidivistic offending and mortality in alcoholic violent offenders: a prospective follow-up study.

Predictive data supporting prevention of violent criminality are scarce. We examined risk factors for recidivism and mortality among non-psychotic alcoholic violent offenders, the majority having antisocial or borderline personality disorders, or both, which is a group that commits the majority of violent offences in Finland. Criminal records and mortality data on 242 male alcoholic violent offenders were analysed after a 7- to 15-year follow-up, and compared between themselves and with those of 1210 age-, sex- and municipality-matched controls. Recidivism and mortality rates were high. The risk of recidivistic violence was increased by antisocial or borderline personality disorder, or both, childhood maltreatment, and a combination of these. A combination of borderline personality disorder and childhood maltreatment was particularly noxious, suggesting an additive risk increase for a poor outcome. Accurate diagnosis and careful childhood interview may help to predict recidivism and premature death.

Qualitative analysis of Coroners' data into the unnatural deaths of children and adolescents.

INTRODUCTION: Unintentional injury and suicide are leading causes of death for adolescents, and reducing these is an important health priority. Coroners' records provide a valuable source of information on the events leading up to the death of an individual, and analysis of these records may help our understanding of the causal pathway, and elucidate potential areas for intervention. METHOD: All cases of unnatural death (poisoning, violence, unintentional injury) in young people aged 8-18 between 1996 and 2002 were identified from the death registers of one region in the UK. Data from Coroners' inquests were analysed to determine cause of death and involvement of professional agencies. A thematic analysis of the transcripts of statements presented at inquests aimed to identify areas of concern in the time immediately prior to death. RESULTS: A total of 77 cases were identified of whom 16 (20.8%) died from alcohol/drug misuse, 20 (26%) by suicide or probable suicide and 41 (53.2%) by other injuries and poisoning. Thematic analysis highlighted: bullying, teenage sexualization and pregnancy, alcohol and substance misuse, reconstituted family difficulties and out of control behaviour as being significant factors on the causal pathway. CONCLUSION: This study based on comprehensive data from one region highlights some of the difficulties faced by young people as they negotiate how to deal with complex emotions and relationships. It also demonstrates how some parents and carers are uncertain about how to address their concerns. Finally, it shows how mortality among young people could potentially be markedly reduced if availability of alcohol and illicit and prescribed substances were reduced.

Premature mortality among males with substance use disorders.

OBJECTIVE: Previous studies have demonstrated that substance use disorders (SUD) are associated with premature mortality in clinical populations, though findings regarding the effect of antisocial personality disorder (ASP) on mortality among persons with SUD are less clear. However, it is unclear to what extent that finding generalizes to persons with SUD in the community, because very little work has been done involving mortality in longitudinal studies of mortality associated with SUD. The objective of this study was to assess whether the presence of SUD or ASP is associated with early mortality among males (fathers) in a predominantly community sample, using a 15-year prospective longitudinal study design. METHOD: We conducted a prospective longitudinal study of adolescents and their fathers. The adolescent subjects were recruited at age 10-12 years, with follow-up evaluations at ages 14, 16, 19, 22, and 25. Questions were asked about paternal mortality during each of those visits. The study sample for this study was the 769 fathers of the adolescent subjects, who included N=341 fathers with a DSM-III-R diagnosis of SUD and N=428 control fathers without a SUD. 89% of these fathers were recruited from the community, and 11% were recruited from clinical sources. Comorbidity patterns were described. A multivariate Cox regression analysis was performed with the father's age at death or last assessment as the dependent variable, and education, SUD, and ASP as the independent variables. RESULTS: Lower education level, the presence of a substance use disorder, and the presence of antisocial personality disorder were significantly associated with earlier mortality (Wald=5.1, df=1, p=0.024; Wald=5.1, df=1, p=0.024, and Wald=5.5, df=1, p=0.019, respectively). Most subjects died from medical illnesses, as opposed to drug overdoses or accidents, which is different from the pattern often noted in clinical samples. CONCLUSIONS: The results of this study demonstrate that the presence of SUD, the presence of ASP, and a lower education level were associated with early mortality in our primarily community-based sample, which extends previous reports of similar findings in clinical samples. The magnitude of the prematurity of the deaths was less that that generally noted in previous studies involving clinical samples, and the causes of death were also somewhat different from those noted in clinical samples. The majority of cases of mortality in our SUD sample resulted from medical illnesses rather than from accidents or overdoses.

Psychiatric severity and mortality in substance abusers: a 15-year follow-up of drug users.

Previous research has shown that most transitions into abstinence happens in the stages of the drug career quickly after the first treatment episode. Mortality is somewhat reduced for patients who become abstinent, but remains high for patients who remain addicted. However, even among substance abusers who become abstinent, mortality is often higher than in the general population. A consecutive sample of drug users admitted for detoxification was followed for 15 years. Face-to-face interviews were conducted at 5-year follow-up. At 15-year follow-up, 24% were dead. Cox proportional hazard regression was conducted to predict mortality for continuous variables, and Gehan's Wilcoxon test was used to predict mortality for dichotomous variables. Psychiatric status at 5-year follow-up was predictive of 15-year mortality, whereas abstinence was not. Subjects who later died had higher scores on the Symptom Checklist 90 [SCL-90] Global Severity Index, lower meaningfulness on the Sense of Coherence scale, and lower Global Assessment of Functioning [GAF] scores at 5-year follow-up. By contrast, there were no associations between baseline drug use and antisocial personality disorder diagnoses and mortality. Psychiatric treatment, including psychotherapy, may be more life-saving for substance abusers than drug-abuse services.

Risk factors for suicide in blacks and whites: an analysis of data from the 1993 National Mortality Followback Survey.

OBJECTIVE: Data on risk factors for suicide in blacks in the United States are needed, given the dramatic increase in the black suicide rate from 1980 to 1997. The 1993 National Mortality Followback Survey represented an unprecedented opportunity to identify risk factors for suicide in blacks and to determine whether race differences (black versus white) in risk factors exist. METHOD: Multiple logistic regression analyses were used to compare cases of suicide (150 suicides in blacks and 1,279 suicides in whites) with cases of accidental deaths (737 cases in blacks and 3,458 cases in whites). Predictors of interest were 18 items tapping four domains: antisocial behavior, substance use/abuse, depressive symptoms, and psychotic symptoms. RESULTS: Four items distinguished suicides from accidental deaths in both black and whites: death ideation, suicidal ideation, bizarre behavior, and making violent threats. Items in two of the four domains discriminated risk for suicide in whites more strongly than in blacks: reports of community complaints and problem drinking. No variable conferred greater risk for suicide in blacks than in whites. CONCLUSIONS: The current study underscores the need for examination of race differences in risk factors for suicide. It is also essential to examine variables that were unavailable in the National Mortality Followback Survey data set, particularly racism, perceived discrimination, and feelings of alienation from the dominant culture.

Total serum cholesterol level, violent criminal offences, suicidal behavior, mortality and the appearance of conduct disorder in Finnish male criminal offenders with antisocial personality disorder.

Associations between low total serum cholesterol (TC) levels and antisocial personality disorder (ASPD), violent and suicidal behavior have been found. We investigated the associations between TC levels, violent and suicidal behavior, age of onset of the conduct disorder (CD) and the age of death among 250 Finnish male criminal offenders with ASPD. The CD had begun before the age of 10 two times more often in non-violent criminal offenders who had lower than median TC levels. The violent criminal offenders having lower than median TC levels were seven times more likely to die before the median age of death in the study material. The violent offenders having lower than median TC levels were eight times more likely to die of unnatural causes. The mean TC level of these male offenders with ASPD was lower than that of the general Finnish male population. Low TC levels are associated with childhood onset type of the CD, and premature and unnatural mortality among male offenders with ASPD. The TC level seems to be a peripheral marker with prognostic value among boys with conduct disorder and antisocial male offenders.

Death rates in 71 men with antisocial personality disorder. A comparison with general population mortality.

Mortality data are presented from a 16- to 45-year follow-up study of 71 men with antisocial personality disorder. Death ascertainment was made through both a personal follow-up and use of the National Death Index. Comparisons were made with the mortality experience of the general population of the state of Iowa by using gender and age standardized mortality ratios. Seventeen men died (24%) died during the follow-up. Antisocial men younger than 40 years were at excessive risk for premature death (standardized mortality ratio [SMR] = 33, P < 0.25): men between ages 40 and 60 years also appeared to be at risk for premature death, although the excess was not statistically significant. Three subjects (18% of all deaths) died of complications from diabetes mellitus (SMR = 14, P < 0.05). Deaths were spread out among the four decades of follow-up. The findings and their implications are discussed.

Assessing gender interactions in the prediction of mortality in alcoholic men and women: a 20-year follow-up study.

This study investigates the predictors of mortality in 259 male and female alcoholics who were psychiatrically hospitalized between 1967 and 1968 and followed for > 20 years. The findings showed that, in addition to age, marital status, medical complications, and non-antisocial personality comorbidity were important independent predictors of time to death. Data pointed to gender interactions, in that marital disruption tended to be a stronger predictor of mortality in men, and delirium tremens tended to be a stronger predictor of mortality in women. Knowing and understanding that certain events and processes may differentially affect the survival of male and female alcoholics will allow for the development of more individualized and gender-specific therapeutic interventions.

The development of antisocial behaviour and sudden violent death.

In order to detect possible relationships between antisocial behaviour and the incidence of "sudden violent death" in young people, information relating to mortality in antisocial Swedish adolescents has been traced and compiled. A register was drawn up covering those young persons (1,056; 832 boys and 224 girls; mean age 16 years) who were admitted to Swedish probationary schools during the period 1 January - 31 December 1967. Using the registers of immigration and emigration, and causes of death kept by SCB (Statistiska Centralbyrån), mortality occurring between 1 January 1967 - 31 December 1985 was tabulated. One hundred and ten boys (13%) and 22 girls (10%) had died. The deaths had occurred at a rate of approximately seven new deaths per observation year, the youngest being still in their teens when they died. For comparison, the criteria set up by insurance companies for life insurance premiums are based on a death expectancy for healthy Swedish boys and girls in the age groups corresponding to the subjects under observation of 1.2-3.1% for boys and 1.1-2.6% for girls. Eighty-eight percent of the dead boys and 77% of the dead girls had died "sudden violent deaths" - accidents, suicides, death from uncertain causes, murder/manslaughter, or alcohol/drug abuse. For both sexes, death from uncertain causes and suicides were the most frequent single causes of death. Death as a direct result of alcohol/drug abuse occurred only in boys. The results give support to the assumption that a link exists between childhood environment, the development of antisocial behaviour/mental insufficiency and a "sudden violent death" at an early age.(ABSTRACT TRUNCATED AT 250 WORDS)

Mortality in a follow-up of 500 psychiatric outpatients. II. Cause-specific mortality.

In a six- to 12-year follow-up study of 500 psychiatric outpatients, death from natural causes occurred 11/2 times the expected rate, although the excess was not significant. Death from unnatural causes occurred 31/2 times the expected rate, a significant elevation. Suicide and homicide rates were particularly excessive. Unnatural mortality was excessive among younger, but not older, patients, and among all sex-race groups except black women, none of whom died unnaturally. Initial psychiatric diagnoses highly predictive of unnatural death included alcoholism, antisocial personality, drug addiction, and homosexuality. Secondary affective disorder was predictive of excess unnatural mortality, but in all cases of such death one of the four disorders associated with excess mortality antedated the affective disturbance. No patient with an index diagnosis of primary affective disorder died of an unnatural cause. Despite a frequent history of suicide attempts, hysteria was not associated with excess unnatural mortality.

Mortality in a follow-up of 500 psychiatric outpatients. I. Total mortality.

Total or all-cause mortality data were determined from a prospective study of 500 randomly selected psychiatric outpatients during a mean follow-up period of seven years. With the use of age-, sex-, and race-adjusted methods, a mortality nearly twice that expected from reference population rates was observed. Mortality was excessive among younger, but not older, patients; and among white men and women and black men, but not among black women. Certain psychiatric diagnoses (based on structured personal interviews performed at index and using explicit criteria) were associated with excess mortality: alcoholism, antisocial personality, drug addiction, homosexuality, organic brain syndrome, and schizophrenia. Excess mortality was not observed among patients with primary affective disorders, ie, disorders not antedated by nonaffective psychiatric illness.

[Frequency of suicidal acts in psychoses]. / K voprosu o chastote suitsidal'nykh deistvii pri psikhozakh.

Psychotic patients committing suicide constitute about 10,0% of all the suicide population and not more than 2,0% of all mental patients. Accomplished suicides are committed by mentally ill and psychotic patients 26 times more frequently than suicides without psychoses, and more frequently in the initial phase of the disease. The highest suicidal activity is seen in alcoholic psychoses and psychoses with anxious-depressive syndromes.

Conditions predisposing to suicide: a review.

By reviewing causes of death among cohorts of various major disease entities or conditions, one may infer that a large majority of suicides are associated with a relatively small number of conditions. From the available follow-up studies, we might estimate that the following percentage of affected individuals will die by suicide: primary (endogenous) depression, 15 per cent; reactive (neurotic) depression, 15 per cent; alcoholism, 15 per cent; schizophrenia, 10 per cent; psychopathic personality, 5 per cent; opiate addiction, 10 per cent or more. Rough estimates of the number of suicides per year in the United States attributable to each condition might be as follows (using low incidence figures): depression, 12,900; alcoholism, 6,900; schizophrenia, 3,800; psychopathy, 2,000 (?); drug addiction, 900.