Eva Tuninger

A Comparison of General Adult and Forensic Patients with Schizophrenia Living in the Community

Schizophrenia is associated with an elevated risk for violence. The response has been to incarcerate people with schizophrenia and to increase the number of forensic beds. Most of these beds are filled by men with schizophrenic disorders with long histories of offending and of treatment in general psychiatry. Outcome from forensic, as compared to general psychiatric services, is unknown. The present study compared outcome defined as levels of positive and negative symptoms, readmission, and aggressive behavior for 248 men with schizophrenic disorders (150 discharged from forensic hospitals and 98 from general adult wards) during a two-year period after discharge from forensic and general psychiatric services. Patients were intensively assessed at discharge and four times during the subsequent two years. Illicit drug use was assessed both objectively and by self-report. More of the forensic than the general patients had failed to complete high school, had displayed a stable pattern of antisocial behavior since at least mid-adolescence, and had convictions for non-violent and violent offences. At discharge and throughout the follow-up period, general patients displayed higher levels of positive and negative symptoms than forensic patients, and more of them engaged in aggressive behavior towards others. Aggressive behavior was associated with positive symptoms and Antisocial Personality Disorder. Rates of readmission were similar for the two groups. The forensic approach that includes assessing and managing the risk of violence as well as treating symptoms of schizophrenia led to better outcome than that of general psychiatry.

Using the HCR-20 to predict aggressive behavior among men with schizophrenia living in the community: Accuracy of prediction, general and forensic settings, and dynamic risk factors.

The HCR-20 is widely used to assess risk of violence among patients with schizophrenia. Further understanding of the accuracy and changes over time in C and R scores is needed. Using prospectively collected data on 248 men with schizophrenia, the present study found that the HCR-20 significantly predicted aggressive behavior over 24 months. The H, C, R, HCR-20 total, and final risk judgment scores were unable to predict aggressive behavior better than chance among the general psychiatric patients in the first six months after discharge. Changes in three C items, the total R score, and in three R items significantly predicted changes in aggressive behavior.

A Multisite Study of Community Treatment Programs for Mentally Ill Offenders With Major Mental Disorders Design, Measures, and the Forensic Sample

This article presents reasons for undertaking “The Comparative Study of the Prevention of Crime and Violence by Mentally Ill Persons” and reasons for decisions regarding the study design and choice of measures. A brief portrait of the forensic patients that have been recruited is also presented. Community treatment programs could offer long-term cost-effective care for offenders with major mental disorders (MMDs). The study aims to identify the necessary ingredients of an effective program. Sites are selected in four countries where identification of most, if not all, persons with MMD who commit crimes within the catchment area was possible. Within each site, two samples of patients with MMD are recruited, one from a forensic hospital and one from a general psychiatric hospital. Assessments are completed prior to discharge. Participants are followed during a 5-year period. Comparisons of the forensic patients recruited in the four sites indicate many more similarities than differences.

Psychosis in adulthood is associated with high rates of ADHD and CD problems during childhood

Abstract Background: Patients diagnosed with schizophrenia display poor premorbid adjustment (PPA) in half of the cases. Attention deficit/hyperactivity disorder (ADHD) and conduct disorder (CD) are common child psychiatric disorders. These two facts have not previously been linked in the literature. Aims: To determine the prevalence of ADHD/CD problems retrospectively among patients with psychoses, and whether and to what extent the high frequency of substance abuse problems among such patients may be linked to ADHD/CD problems. Method: ADHD and CD problems/diagnoses were retrospectively recorded in one forensic (n = 149) and two non-forensic samples (n = 98 and n = 231) of patients with a psychotic illness: schizophrenia, bipolar or other, excluding drug-induced psychoses. Results: ADHD and CD were much more common among the patients than in the general population—the odds ratio was estimated to be greater than 5. There was no significant difference in this respect between forensic and non-forensic patients. Substance abuse was common, but substantially more common among patients with premorbid ADHD/CD problems. Conclusions: Previous views regarding PPA among patients with a psychotic illness may reflect an association between childhood ADHD/CD and later psychosis. The nature of this association remains uncertain: two disorders sharing some generative mechanisms or one disorder with two main clinical manifestations. Childhood ADHD and particularly CD problems contribute to the high frequency of substance abuse in such groups.

Schizophrenia--progressive and massive decline in response readiness by episodes.

Objective: To relate the pattern of neuropsychological impairments among schizophrenic patients to case history data and disease characteristics in a cross‐sectional study of unselected patients, and to integrate these data with two previous longitudinal studies of neuropsychological impairments among schizophrenic patients.

Neuropsychological impairment in patients treated with depot neuroleptics:a longitudinal study

Objective: To assess neuropsychological impairments among chronic functional psychotic patients over time, and relations with symptoms, drug dose and side effects.

Long‐term outcome of depot neuroleptic maintenance treatment among chronic psychotic patients

A total of 51 chronic psychotic out‐patients, with a median age of 51 years and median duration of psychosis of 23 years, treated with depot neuroleptics, entered a 5‐year follow‐up study with assessments of symptoms, side‐effects and plasma concentration of the depot drug (follow‐up (FU) patients). The outcome for 38 non‐eligible (NE) patients was obtained from hospital case reports. The relapse rate was higher for NE than for FU patients (71% vs. 50%). The mortality rate was 9%, and the median age at death was 47 years. Half of the FU patients completed 3 years of treatment uneventfully. Of the total of 89 patients, only 18% remained stable over a period of 5 years. The depot dose was approximately the same after 3 years (median 255 mg, range 50–1018 mg chlorpromazine equivalents).

PECC-Factor structure and findings in three longitudinal cohorts of patients with schizophrenia

Background: Symptom control by drug treatment is the most important task in routine clinical care of patients with schizophrenia. Structured assessment methods are needed in this task but not used much. The US-developed Positive and Negative Syndrome Scale (PANSS) is a standard tool for symptom assessment. The Psychosis Evaluation tool for Common use by Caregivers (PECC) was constructed in Europe some years ago, with the intent to overcome some of the PANSS drawbacks. Aims and methods: To validate PECC on three longitudinal cohorts of schizophrenic patients representative of Swedish outpatients (n = 225, six assessments over 5 years), international forensic patients (n = 186) and matched non-forensic controls (n = 116), five assessments over 2 years for both. Results: The factor structure of PECC appears to be highly robust. Norm values (in percentiles) were calculated on the materials. Such data provides for analyses of symptom profiles and improvement over time measured in absolute numbers. Forensic patients appear to have a much lower symptom load (except for cognitive symptoms) than the other groups. Forensic controls had much shorter inpatient times than any other group and never caught up with respect to symptom control, even after 2 years. These differences suggest that the scale is clinically valid. Conclusion: PECC has a more robust factor structure than PANSS and is simpler to use. Percentile norms have been constructed for outpatients with schizophrenia in general and forensic psychiatry. Percentile scores are accessed readily by the net. PECC is available in many languages. Its separate self-harm item may improve assessments of suicide risk among patients with schizophrenia.

A modified Drug Attitude Inventory used in long-term patients in sheltered housing

The self-report Drug Attitude Inventory (DAI), in 30- and 10-item versions, provides unique information of clinical relevance for monitoring treatment adherence among people diagnosed with schizophrenia. The primary purpose of this paper was to evaluate the 10-item version among patients living in sheltered housing. Data were collected among 68 persons living in sheltered housing, most of them (82%) diagnosed with schizophrenia, 6% with non-organic psychoses, and 12% with other diagnoses. The dichotomic response format of the original DAI-10 was replaced by a 4-point Likert scale, in order to improve the resolution of the scale. Over 90% of the participants produced meaningful scores. A factor analysis suggested a 2-factor orthogonal structure: one highly homogenous factor (5 items) reflected wanted effects of the drug and displayed a bimodal distribution; one factor (3 items) reflected side effects. One item concerned the perceived control over ones drug treatment, which is a key clinical issue. One item was conceptually ambiguous and displayed no correlations with the other items. On the basis of the results we suggest cut-off scores which indicate the need for three kinds of adherence-improving interventions. Summing up, by dropping one item and using a Likert scale response format, the resulting instrument, DAI-9, appears to be an easy-to-use self-report instrument for monitoring drug attitudes and to identify needs for treatment adherence interventions among seriously ill patients.

Dopamine D2-receptor density in humans as assessed with SPET and the new high-affinity ligand 123I-NCQ298: a pilot study.

Astra (S)-3-[123I]iodo-5,6-dimethoxyl-N-[(1-ethyl-2-pyrrolidinyl)methyl] -salicylamide (123I-NCQ298) is a new high-affinity D2-receptor ligand for use in single photon emission tomography (SPET) studies. We have studied the biodistribution and absorbed radiation dose of 123I-NCQ298 in humans. The mean effective dose for adults was 0.055 mSv MBq(-1). Brain uptake and clearance was measured with a head dedicated SPET camera. 123I-NCQ298 showed specific uptake in the basal ganglia with a low clearance rate (time constant of 9-34 h). The extrastriatal binding was variable (average 30%, maximum 60% of that in the basal ganglia at 1 h), but with a clearance rate twice that of the basal ganglia. The fairly high level of extrastriatal binding precluded the use of a quotient between the basal ganglia and cerebellum-to-frontal cortex 123I-NCQ298 concentration as a measure for basal ganglia D2-receptor density. Chronic schizophrenic patients treated with conventional neuroleptics had a decreased affinity for 123I-NCQ298 in the basal ganglia in the range 10-60% of the median value for the control, untreated subjects.