Mechanisms Involved in Thromboxane A2 -induced Vasoconstriction of Rat Intracavernous Small Penile Arteries.

Diabetes is associated with erectile dysfunction and with hypercontractility in erectile tissue and this is in part ascribed to increased formation of thromboxane. Rho kinase (ROCK) is a key regulator of calcium sensitization and contraction in vascular smooth muscle. This study investigated the role of calcium and ROCK in contraction evoked by activation of the thromboxane receptors. Rat intracavernous penile arteries were mounted for isometric tension and intracellular calcium ([Ca2+ ]i ) recording and corpus cavernosum for measurements of MYPT1 phosphorylation. In penile arteries, U46619 by activation of thromboxane receptors concentration dependently increased calcium and contraction. U46619-induced calcium influx was blocked by nifedipine, a blocker of L-type calcium channels, and by 2-aminoethoxydiphenyl borate, a blocker of transient receptor potential (TRP) channels. Inhibitors of ROCK, Y27632 and glycyl-H1152P, concentration dependently reduced U46619-induced contraction, but only Y27632 reduced [Ca2+ ]i levels in the penile arteries activated with either high extracellular potassium or U46619. MYPT-Thr850 phosphorylation in corpus cavernous strips was increased in response to U46619 through activation of TP receptors and was found to be a direct result of phosphorylation by ROCK. Y27632 induced less relaxation in mesenteric arteries, H1152P induced equipotent relaxations, and a protein kinase C inhibitor, Ro-318220, failed to relax intracavernous penile arteries, but induced full relaxation in rat mesenteric arteries. Our findings suggest that U46619 contraction depends on Ca2+ influx through L-type and TRP channels, and ROCK-dependent mechanisms in penile arteries. Inhibition of the ROCK pathway is a potential approach for the treatment of erectile dysfunction associated with hypertension and diabetes.

La práctica de la evaluación del riesgo de violencia en España / The practice of violence risk assessment in Spain

Antecedentes. La valoración del riesgo de violencia es un requisito fundamental en la toma de decisiones profesionales que implican prevenir, intervenir o informar sobre la conducta de las personas. El uso de herramientas estructuradas de evaluación del riesgo de violencia ha mostrado mejoría en la precisión de las evaluaciones basadas exclusivamente en el juicio clínico o en la pericia de un experto en contextos psiquiátricos, penitenciarios y jurídicos. Objetivo. Este estudio presenta los resultados de la primera encuesta sobre las prácticas profesionales asociadas al uso de herramientas de evaluación del riesgo de violencia en España. Materiales y métodos. La información fue recogida mediante la administración de una encuesta en internet que fue distribuida por correo electrónico a los miembros de organizaciones profesionales. Resultados. De manera similar a los contextos profesionales del resto del mundo, las escalas de psicopatía de Robert Hare (Psychopathy Checklist-Revised y Psychopathy Checklist: Screening Version) y el Historical-Clinical-Risk Management-20 encabezaron la lista de las herramientas más usadas tanto por elección personal como por requisito institucional. Conclusiones. Se ofrecen datos novedosos sobre la prevalencia de uso y la utilidad percibida de las herramientas estructuradas, así como sobre otras cuestiones relacionadas a las prácticas profesionales de evaluación del riesgo de violencia en España que pueden orientar tanto a los profesionales de contextos sanitarios, correccionales y forenses, como a los responsables de las instituciones en la elección de las herramientas a implementar para asistirlos en la toma de decisiones.

Background. Violence risk assessment is a key requirement in professional decision making involving prevention, intervention or reporting on human behavior. The use of structured tools for violence risk assessment has shown to improve the accuracy of assessments based exclusively on clinical judgment or expertise in psychiatric, correctional and legal settings. Objectives. This study presents results of the first survey about professional practices associated with tools for violence risk assessment in Spain. Materials and methods. The information was collected by administering an online-based survey that was distributed by e-mail to members of professional organizations around the country. Results. As in professional contexts worldwide, the Robert Hare's psychopathy scales (Psychopathy Checklist-Revised and Psychopathy Checklist: Screening Version) and the Historical-Clinical-Risk Management-20 topped the list of the most used tools both by professional choice and institutional requirement. Conclusions. We provide novel data on the prevalence of use and the perceived utility of specific tools, as well as on other issues related to the professional practice of violence risk assessment in Spain, which can guide professional in the health care, correctional and forensic settings, as well as those responsible for decisions in institutions about choosing which tool to implement.

Cardiovascular effects of current and future anti-obesity drugs.

The prevalence of obesity increases and is associated with increases in co-morbidities e.g. type 2 diabetes, hyperlipidemia, hypertension, obstructive sleep apnea, heart disease, stroke, asthma, several forms of cancer, depression, and may result in reduction of expected remaining lifespan. We have reviewed the adverse effects on the cardiovascular system of anti-obesity drugs now retracted from the market as well as the cardiovascular profile of current drugs and potential pathways which are considered for treatment of obesity. Fenfluramine, and sibutramine were withdrawn due to increased cardiovascular risk, while an inverse agonist at cannabinoid type 1 (CB1) receptors, rimonobant was withdrawn due to serious psychiatric problems. At present there are only few treatments available including orlistat and, phentermine alone or in combination with topiramate and lorcaserin, although cardiovascular side effects need to be clarified regarding phentermine and lorcaserin. Drugs approved for type 2 diabetes including glucagon like peptide (GLP-1) analogues and metformin also cause moderate weight losses and have a favourable cardiovascular profile, while the anti-obesity potential of nebivolol remains unexplored. Pathways with anti-obesity potential include sirtuin activation, blockade of transient receptor potential (TRPV1) channels, acetyl-CoA carboxylase 1 and 2 inhibitors, uncoupling protein activators, bile acids, crotonins, CB1 antagonists, but the cardiovascular profile remains to be investigated. For type 2 diabetes, new drug classes with possible advantageous cardiovascular profiles, e.g. GLP-1 analogues and sodium-glucose co-transport type 2 inhibitors, are associated with weight loss and are currently being evaluated as anti-obesity drugs.

Authorship bias in violence risk assessment? A systematic review and meta-analysis.

Various financial and non-financial conflicts of interests have been shown to influence the reporting of research findings, particularly in clinical medicine. In this study, we examine whether this extends to prognostic instruments designed to assess violence risk. Such instruments have increasingly become a routine part of clinical practice in mental health and criminal justice settings. The present meta-analysis investigated whether an authorship effect exists in the violence risk assessment literature by comparing predictive accuracy outcomes in studies where the individuals who designed these instruments were study authors with independent investigations. A systematic search from 1966 to 2011 was conducted using PsycINFO, EMBASE, MEDLINE, and US National Criminal Justice Reference Service Abstracts to identify predictive validity studies for the nine most commonly used risk assessment tools. Tabular data from 83 studies comprising 104 samples was collected, information on two-thirds of which was received directly from study authors for the review. Random effects subgroup analysis and metaregression were used to explore evidence of an authorship effect. We found a substantial and statistically significant authorship effect. Overall, studies authored by tool designers reported predictive validity findings around two times higher those of investigations reported by independent authors (DOR=6.22 [95% CI=4.68-8.26] in designers' studies vs. DOR=3.08 [95% CI=2.45-3.88] in independent studies). As there was evidence of an authorship effect, we also examined disclosure rates. None of the 25 studies where tool designers or translators were also study authors published a conflict of interest statement to that effect, despite a number of journals requiring that potential conflicts be disclosed. The field of risk assessment would benefit from routine disclosure and registration of research studies. The extent to which similar conflict of interests exists in those developing risk assessment guidelines and providing expert testimony needs clarification.

Perinatal risk factors in offenders with severe personality disorder: a population-based investigation.

Although perinatal factors are associated with the development of several psychiatric disorders, it is unknown whether these factors are linked with personality disorder. Cases of personality disorder were drawn from a national registry of all forensic psychiatric evaluations (n = 150). Two control groups were used: (1) A sample of forensic evaluations without any psychiatric disorder (n = 97) allowing for a nested case-control investigation; and (2) A population-based sample matched by age and gender with no history of psychiatric hospitalization (n = 1498). Prematurity (<37 weeks of completed gestation) was significantly associated with a diagnosis of personality disorder, both in the nested and the population-based case-control comparisons with adjusted odds ratios (OR) for this risk factor ranging from 2 to 4. Asphyxia (adjusted OR = 2.4, 95% CI: 1.4-4.1) and complicated delivery (adjusted OR = 1.5, 1.0-2.1) were associated with personality disorder in the population-based study, and the former remained significant in multivariate models. Overall, perinatal complications were found to be associated with a later diagnosis of personality disorder in this selected sample. As with other psychiatric disorders where such associations have been demonstrated, changes during the perinatal period may lead to abnormal brain development and function.

Use of risk assessment instruments to predict violence and antisocial behaviour in 73 samples involving 24 827 people: systematic review and meta-analysis.

OBJECTIVE: To investigate the predictive validity of tools commonly used to assess the risk of violence, sexual, and criminal behaviour. DESIGN: Systematic review and tabular meta-analysis of replication studies following PRISMA guidelines. DATA SOURCES: PsycINFO, Embase, Medline, and United States Criminal Justice Reference Service Abstracts. REVIEW METHODS: We included replication studies from 1 January 1995 to 1 January 2011 if they provided contingency data for the offending outcome that the tools were designed to predict. We calculated the diagnostic odds ratio, sensitivity, specificity, area under the curve, positive predictive value, negative predictive value, the number needed to detain to prevent one offence, as well as a novel performance indicator-the number safely discharged. We investigated potential sources of heterogeneity using metaregression and subgroup analyses. RESULTS: Risk assessments were conducted on 73 samples comprising 24,847 participants from 13 countries, of whom 5879 (23.7%) offended over an average of 49.6 months. When used to predict violent offending, risk assessment tools produced low to moderate positive predictive values (median 41%, interquartile range 27-60%) and higher negative predictive values (91%, 81-95%), and a corresponding median number needed to detain of 2 (2-4) and number safely discharged of 10 (4-18). Instruments designed to predict violent offending performed better than those aimed at predicting sexual or general crime. CONCLUSIONS: Although risk assessment tools are widely used in clinical and criminal justice settings, their predictive accuracy varies depending on how they are used. They seem to identify low risk individuals with high levels of accuracy, but their use as sole determinants of detention, sentencing, and release is not supported by the current evidence. Further research is needed to examine their contribution to treatment and management.

Long-term functional outcome in adult prison inmates with ADHD receiving OROS-methylphenidate.

In a recent randomized, double-blind, placebo-controlled trial, we established a robust efficacy (Cohen's d = 2.17) of osmotic release oral system-methylphenidate (OROS-methylphenidate) delivered 72 mg daily for 5 weeks versus placebo on attention deficit hyperactivity disorder (ADHD) symptoms, global severity and global functioning in 30 adult male prison inmates with ADHD and coexisting disorders. Outcomes continued to improve during the subsequent 47-week open-label extension with OROS-methylphenidate delivered at a flexible daily dosage of up to 1.3 mg/kg body weight. In the present study, we evaluated long-term effectiveness and maintenance of improvement over the cumulated 52-week trial on cognition, motor activity, institutional behaviour and quality of life. Post hoc, we explored the associations between investigators' and self-ratings of ADHD symptoms and between ratings of symptoms and functioning, respectively. Outcomes, calculated by repeated measures ANOVA, improved from baseline until week 16, with maintenance or further improvement until week 52. Both verbal and visuospatial working memory, and abstract verbal reasoning improved significantly over time, as well as several cognition-related measures and motor activity. No substance abuse was detected and a majority of participants took part in psychosocial treatment programmes. The quality of life domains of Learning, and Goals and values improved over time; the latter domain was at open-label endpoint significantly related to improvements in attention. Investigators' and self-ratings of ADHD symptoms, as well as global symptom severity related most significantly to global functioning at week 52. Finally, investigators' and self-ratings of ADHD symptoms associated significantly at baseline with increasing convergence over time.

A novel approach to determining violence risk in schizophrenia: developing a stepped strategy in 13,806 discharged patients.

Clinical guidelines recommend that violence risk be assessed in schizophrenia. Current approaches are resource-intensive as they employ detailed clinical assessments of dangerousness for most patients. An alternative approach would be to first screen out patients at very low risk of future violence prior to more costly and time-consuming assessments. In order to implement such a stepped strategy, we developed a simple tool to screen out individuals with schizophrenia at very low risk of violent offending. We merged high quality Swedish national registers containing information on psychiatric diagnoses, socio-demographic factors, and violent crime. A cohort of 13,806 individuals with hospital discharge diagnoses of schizophrenia was identified and followed for up to 33 years for violent crime. Cox regression was used to determine risk factors for violent crime and construct the screening tool, the predictive validity of which was measured using four outcome statistics. The instrument was calibrated on 6,903 participants and cross-validated using three independent replication samples of 2,301 participants each. Regression analyses resulted in a tool composed of five items: male sex, previous criminal conviction, young age at assessment, comorbid alcohol abuse, and comorbid drug abuse. At 5 years after discharge, the instrument had a negative predictive value of 0.99 (95% CI = 0.98-0.99), meaning that very few individuals who the tool screened out (n = 2,359 out of original sample of 6,903) were subsequently convicted of a violent offence. Screening out patients who are at very low risk of violence prior to more detailed clinical assessment may assist the risk assessment process in schizophrenia.

Alcohol use disorders in schizophrenia: a national cohort study of 12,653 patients.

BACKGROUND: Comorbid alcohol use disorders (AUDs) in schizophrenia are associated with increased morbidity, more inpatient treatment, and violent offending. It is of clinical importance to identify those with schizophrenia who may go on to develop an alcohol use disorder; however, the risk factors are not well understood. The aim of this study was to identify risk factors for the development of an AUD in patients after they had been diagnosed with schizophrenia. METHOD: We conducted a retrospective case-control study of 12,653 individuals diagnosed with ICD-defined schizophrenia in Sweden in 1973-2004, using data from national registers. We tested the associations between individual factors (marital status, immigrant status, and previous violent offending), sociodemographic factors (income and education), and parental risk factors (AUDs, psychosis, and violent offending) ICD-defined and AUD development using logistic regression modeling. RESULTS: Over a median follow-up of 17.3 years, 7.6% of patients had at least 1 hospital diagnosis of AUD. After adjustment for gender and age at diagnosis in a multivariate regression model, previous violent offending (OR = 2.1; 95% CI, 1.8-2.5), low education (OR = 1.3; 95% CI, 1.1-1.5), maternal AUD (OR = 1.9; 95% CI, 1.4-2.7), and paternal AUD (OR = 1.9; 95% CI, 1.5-2.3) remained independently associated with increased risk of patient AUD. CONCLUSIONS: AUDs are a common sequela of schizophrenia. Risk factors that could be identified at the time of first presentation include low educational attainment, previous violent offending, and parental history of AUDs and may inform clinical treatment and follow-up of those most at risk.

The genetic and environmental etiology of antisocial behavior from childhood to emerging adulthood.

Previous research suggests that both genetic and environmental influences are important for antisocial behavior across the life span, even though the prevalence and incidence of antisocial behavior varies considerably across ages. However, little is known of how genetic and environmental effects influence the development of antisocial behavior. A total of 2,600 male and female twins from the population-based Swedish Twin Registry were included in the present study. Antisocial behavior was measured on four occasions, when twins were 8-9, 13-14, 16-17, and 19-20 years old. Longitudinal analyses of the data were conducted using structural equation modeling. The stability of antisocial behavior over time was explained by a common latent persistent antisocial behavior factor. A common genetic influence accounted for 67% of the total variance in this latent factor, the shared environment explained 26%, and the remaining 7% was due to the non-shared environment. Significant age-specific shared environmental factors were found at ages 13-14 years, suggesting that common experiences (e.g., peers) are important for antisocial behavior at this age. Results from this study show that genetic as well as shared environmental influences are important in antisocial behavior that persists from childhood to emerging adulthood.

A comparative study of violence risk assessment tools: a systematic review and metaregression analysis of 68 studies involving 25,980 participants.

There are a large number of structured instruments that assist in the assessment of antisocial, violent and sexual risk, and their use appears to be increasing in mental health and criminal justice settings. However, little is known about which commonly used instruments produce the highest rates of predictive validity, and whether overall rates of predictive validity differ by gender, ethnicity, outcome, and other study characteristics. We undertook a systematic review and meta-analysis of nine commonly used risk assessment instruments following PRISMA guidelines. We collected data from 68 studies based on 25,980 participants in 88 independent samples. For 54 of the samples, new tabular data was provided directly by authors. We used four outcome statistics to assess rates of predictive validity, and analyzed sources of heterogeneity using subgroup analysis and metaregression. A tool designed to detect violence risk in juveniles, the Structured Assessment of Violence Risk in Youth (SAVRY), produced the highest rates of predictive validity, while an instrument used to identify adults at risk for general offending, the Level of Service Inventory-Revised (LSI-R), and a personality scale commonly used for the purposes of risk assessment, the Psychopathy Checklist-Revised (PCL-R), produced the lowest. Instruments produced higher rates of predictive validity in older and in predominantly White samples. Risk assessment procedures and guidelines by mental health services and criminal justice systems may need review in light of these findings.

Risk of violent crime in individuals with epilepsy and traumatic brain injury: a 35-year Swedish population study.

BACKGROUND: Epilepsy and traumatic brain injury are common neurological conditions, with general population prevalence estimates around 0.5% and 0.3%, respectively. Although both illnesses are associated with various adverse outcomes, and expert opinion has suggested increased criminality, links with violent behaviour remain uncertain. METHODS AND FINDINGS: We combined Swedish population registers from 1973 to 2009, and examined associations of epilepsy (n = 22,947) and traumatic brain injury (n = 22,914) with subsequent violent crime (defined as convictions for homicide, assault, robbery, arson, any sexual offense, or illegal threats or intimidation). Each case was age and gender matched with ten general population controls, and analysed using conditional logistic regression with adjustment for socio-demographic factors. In addition, we compared cases with unaffected siblings. Among the traumatic brain injury cases, 2,011 individuals (8.8%) committed violent crime after diagnosis, which, compared with population controls (n = 229,118), corresponded to a substantially increased risk (adjusted odds ratio [aOR] = 3.3, 95% CI: 3.1-3.5); this risk was attenuated when cases were compared with unaffected siblings (aOR = 2.0, 1.8-2.3). Among individuals with epilepsy, 973 (4.2%) committed a violent offense after diagnosis, corresponding to a significantly increased odds of violent crime compared with 224,006 population controls (aOR = 1.5, 1.4-1.7). However, this association disappeared when individuals with epilepsy were compared with their unaffected siblings (aOR = 1.1, 0.9-1.2). We found heterogeneity in violence risk by age of disease onset, severity, comorbidity with substance abuse, and clinical subgroups. Case ascertainment was restricted to patient registers. CONCLUSIONS: In this longitudinal population-based study, we found that, after adjustment for familial confounding, epilepsy was not associated with increased risk of violent crime, questioning expert opinion that has suggested a causal relationship. In contrast, although there was some attenuation in risk estimates after adjustment for familial factors and substance abuse in individuals with traumatic brain injury, we found a significantly increased risk of violent crime. The implications of these findings will vary for clinical services, the criminal justice system, and patient charities.

Mentally disordered offenders' daily occupations after one year of forensic care.

Persons detained as mentally disordered offenders need support for transition from care to community life. Few systematic studies have been completed on the outcomes of standard forensic care. The aim was to investigate the target group's life conditions and daily occupations one year after care. In a follow-up design occupational performance (OP) and social participation (SP) were investigated at two time points. After informed consent 36 consecutively recruited participants reported OP using the Capability to Perform Daily Occupations, Self-Efficacy Scale, Importance scale, and Allen Cognitive Level Screen. SP was measured with the Manchester Short Assessment of Quality of Life, and Interview Schedule for Social Interaction. After one year 24 participants were still incarcerated, 11 were conditionally released, and one participant was discharged. The group were generally more satisfied and engaged in daily occupations than at admission. The study's attrition rate, 51%, is discussed. The conclusion and the clinical implications indicate that the target group need early, goal directed interventions in OP and SP for alterations in daily occupations. Furthermore, to increase the knowledge base concerning mentally disordered offenders, studies with research designs that have the potential to uncover changes in daily occupation and other measures for this target group are necessary.

Is arson the crime most strongly associated with psychosis?--A national case-control study of arson risk in schizophrenia and other psychoses.

BACKGROUND: The association of psychosis with certain serious crimes, such as homicide, has been clearly demonstrated, but it is uncertain to what extent psychotic disorders are associated with arson. METHODS: We used a case-control design to investigate the association of being diagnosed with schizophrenia and other psychoses and committing arson. Data were obtained from Swedish national registers for criminal convictions, hospital discharge diagnoses (International Classification of Diseases, Ninth Revision [ICD-9], and International Classification of Diseases, Tenth Revision [ICD-10]), and sociodemographic factors for 1988-2000. We included all convicted arson offenders of both sexes in Sweden (N=1689) and compared them with a random sample of general population control subjects (N=40,560). RESULTS: After adjustment for sociodemographic confounders, arson offenders were more likely to be diagnosed with schizophrenia (in men, adjusted odds ratio [OR]=22.6, 95% confidence interval [CI]=14.8-34.4; in women, adjusted OR=38.7, 95% CI=20.4-73.5) or other psychoses (in men, adjusted OR=17.4, 95% CI=11.1-27.5; in women, adjusted OR=30.8, 95% CI=18.8-50.6). CONCLUSIONS: Individuals with schizophrenia and other psychoses have significantly increased risks of an arson conviction. These risk estimates are higher than those reported for other violent crimes and place arson in the same category as homicide as crimes that are most strongly associated with psychotic disorders.

Prison suicide in 12 countries: an ecological study of 861 suicides during 2003-2007.

BACKGROUND: Although suicide rates among prisoners are high and vary between countries, it is uncertain whether this reflects the importation of risk from the general population or is associated with incarceration rates. METHODS: We collected data on suicides and undetermined deaths in 12 countries (Australia, Belgium, Canada, Denmark, England and Wales, Finland, Ireland, Netherlands, New Zealand, Norway, Scotland, and Sweden) directly from their prison administrations for 2003-2007. These were compared with rates of suicides in the general population separately by gender using Pearson's correlations. In addition, they were compared with rates of incarceration. Linear regression was used to examine any association after adjustment for rates of incarceration. RESULTS: Data were collected on 861 suicides in prison, of which 810 were in men. In the men, crude relative rates of suicide were at least three times higher than the general population. Western European countries had similar rates of prisoner suicide which were mostly higher than those in Australia, Canada, and New Zealand. There was no association between rates of suicide in prisoners and general population rates or rates of incarceration. In the women, inmate suicide rates varied widely and were mostly raised compared with rates in the general population. In addition, these rates did not appear to be associated with general population rates of suicide. CONCLUSIONS: Rates of prison suicide do not reflect general population suicide rates, suggesting that variations in prison suicide rates reflect differences in criminal justice systems including, possibly, the provision of psychiatric care in prison.

Homicide in discharged patients with schizophrenia and other psychoses: a national case-control study.

OBJECTIVE: To investigate factors associated with homicide after discharge from hospital in patients with schizophrenia and other psychoses. DESIGN: All homicides committed by patients with psychosis within 6 months of hospital discharge were identified in Sweden from 1988-2001 and compared with patients with psychoses discharged over the same time period who did not subsequently commit any violent offences. Medical records were then collected, and data extracted using a validated protocol. Interrater reliability tests were performed on a subsample, and variables with poor reliability excluded from subsequent analyses. RESULTS: We identified 47 cases who committed a homicide within 6 months of discharge, and 105 controls who did not commit any violent offence after discharge. On univariate analyses, clinical factors on admission associated with homicide included evidence of poor self-care, substance misuse, and being previously hospitalized for a violent episode. Inpatient characteristics included having a severe mental illness for one year prior to admission. After-care factors associated with homicide were evidence of medication non-compliance and substance misuse. The predictive validity of combining two or three of these factors was not high. Depression appeared to be inversely associated with homicide, and there was no relationship with the presence of delusions or hallucinations. CONCLUSIONS: There are a number of potentially treatable factors that are associated with homicide in schizophrenia and other psychoses. Associations with substance misuse and treatment compliance could be the focus of therapeutic interventions if validated in other samples. However, their clinical utility in violence risk assessment remains uncertain.

Bipolar disorder and violent crime: new evidence from population-based longitudinal studies and systematic review.

CONTEXT: Although bipolar disorder is associated with various adverse health outcomes, the relationship with violent crime is uncertain. OBJECTIVES: To determine the risk of violent crime in bipolar disorder and to contextualize the findings with a systematic review. DESIGN: Longitudinal investigations using general population and unaffected sibling control individuals. SETTING: Population-based registers of hospital discharge diagnoses, sociodemographic information, and violent crime in Sweden from January 1, 1973, through December 31, 2004. PARTICIPANTS: Individuals with 2 or more discharge diagnoses of bipolar disorder (n = 3743), general population controls (n = 37 429), and unaffected full siblings of individuals with bipolar disorder (n = 4059). MAIN OUTCOME MEASURE: Violent crime (actions resulting in convictions for homicide, assault, robbery, arson, any sexual offense, illegal threats, or intimidation). RESULTS: During follow-up, 314 individuals with bipolar disorder (8.4%) committed violent crime compared with 1312 general population controls (3.5%) (adjusted odds ratio, 2.3; 95% confidence interval, 2.0-2.6). The risk was mostly confined to patients with substance abuse comorbidity (adjusted odds ratio, 6.4; 95% confidence interval, 5.1-8.1). The risk increase was minimal in patients without substance abuse comorbidity (adjusted odds ratio, 1.3; 95% confidence interval, 1.0-1.5), which was further attenuated when unaffected full siblings of individuals with bipolar disorder were used as controls (1.1; 0.7-1.6). We found no differences in rates of violent crime by clinical subgroups (manic vs depressive or psychotic vs nonpsychotic). The systematic review identified 8 previous studies (n = 6383), with high heterogeneity between studies. Odds ratio for violence risk ranged from 2 to 9. CONCLUSION: Although current guidelines for the management of individuals with bipolar disorder do not recommend routine risk assessment for violence, this assertion may need review in patients with comorbid substance abuse.

Familial confounding of the association between maternal smoking during pregnancy and offspring criminality: a population-based study in Sweden.

CONTEXT: The association between maternal smoking during pregnancy (SDP) and offspring disruptive behaviors has been well documented, but it is unclear whether exposure to SDP or the effects of factors correlated with SDP account for the increased risk. OBJECTIVE: To test whether the association between SDP and offspring criminal convictions was consistent with a causal connection or due to familial background factors by controlling for measured covariates and using a quasi-experimental approach. DESIGN: We used a population-based study of children born in Sweden from 1983 to 1989 (N = 609,372) to examine the association between SDP and offspring criminal convictions while controlling for measured traits of both parents. We also compared siblings differentially exposed to SDP (n = 50,339) to account for unmeasured familial factors that could account for the association. SETTING: Population-based study of all children born in Sweden from 1983 to 1989 with information on maternal SDP and offspring criminal convictions based on national registries collected by the Swedish government. PATIENTS OR OTHER PARTICIPANTS: Children born in Sweden from 1983 to 1989 (N = 609,372) and siblings differentially exposed to SDP (n = 50,339). MAIN OUTCOME MEASURES: Violent and nonviolent convictions, based on the Swedish National Crime Register, a register with detailed information on all convictions in the country. RESULTS: Moderate (hazard rate [HR], 2.47; 95% confidence interval [CI], 2.34-2.60) and high (HR, 3.43; 95% CI, 3.25-3.63) levels of maternal SDP were associated with an increased risk for offspring violent convictions, even when controlling for maternal and paternal traits. There was no association between SDP and violent convictions, however, when comparing differentially exposed siblings (HR(moderate), 1.02; 95% CI, 0.79-1.30; HR(high), 1.03; 95% CI, 0.78-1.37). Smoking during pregnancy also was associated with nonviolent convictions in the entire population (HR(moderate), 1.62; 95% CI, 1.58-1.66; HR(high), 1.87; 95% CI, 1.82-1.92) and when controlling for covariates. But, there was no association when comparing siblings who were differentially exposed (HR(moderate), 0.89; 95% CI, 0.78-1.01; HR(high), 0.89; 95% CI, 0.78-1.02). CONCLUSION: The results suggest that familial background factors account for the association between maternal SDP and criminal convictions, not the specific exposure to SDP.

Sexual offending in women and psychiatric disorder: a national case-control study.

Women commit 4-5% of all sexual crimes, but there is considerable uncertainty about associations with psychosis and substance abuse. We examined the prevalence of psychiatric hospitalization, psychotic disorders, and substance abuse in a nationwide sample of female sexual offenders. We obtained data from Swedish national registers for criminal convictions, hospital discharge diagnoses, and demographic and socioeconomic factors between 1988 and 2000, and merged them using unique identifiers. Convicted female sexual offenders (n = 93) were compared with all females convicted of non-sexual violent offences (n = 13,452) and a random sample of general population women (n = 20,597). Over 13 years, 36.6% of female sexual offenders had been admitted to psychiatric hospital and 7.5% been discharged with a diagnosis of a psychotic disorder. Compared to non-sexual violent offenders, there were no significant differences in the proportion diagnosed with psychosis or substance abuse. Compared to women in the general population, however, there was a significantly increased risk in sex offenders of psychiatric hospitalization (age-adjusted odds ratio [AOR] = 15.4; 95% CI: 10.0-23.7), being diagnosed with a psychotic disorder (AOR = 16.2; 95% CI: 7.2-36.4), and with substance use disorders (AOR = 22.6; 95% CI: 13.0-39.1). We conclude that the prevalence of psychotic and substance use disorders was not different between sexual offenders and other violent offenders, suggesting non-specificity of sexual offending in women. Nevertheless, substantially increased prevalences of psychiatric disorder, underline the importance of screening and assessment of female sexual and other violent offenders.