Hanna Putkonen

Substance-induced psychoses converting into schizophrenia: a register-based study of 18,478 Finnish inpatient cases.

BACKGROUNDnDespite the clinical importance of substance-induced psychosis (SIP), few studies have examined the course of this condition after its acute manifestation.nnnOBJECTIVEnTo investigate the rate of SIP conversion to a schizophrenia spectrum disorder and the length of follow-up needed to catch the majority of these patients whose diagnoses change. In addition to the conversion rate and pattern, we wanted to look for possible related factors.nnnMETHODnUsing the nationwide Finnish Hospital Discharge Register, we followed all patients (N = 18,478) since their first inpatient hospital admission with a diagnosis of SIP (codes 2921 and 2928 in DSM-III-R and codes F10-F19 in ICD-10 with a third digit of 4, 5, or 7) between January 1987 and December 2003 in Finland. Patients (mean age = 43.7 years, standard deviation = 13.5 years) were followed until first occurrence of schizophrenia spectrum disorder, death, or the end of December 2003, whichever took place first. Conversions of discharge diagnoses into schizophrenia spectrum disorders (codes 2951-2959 and 2971 in DSM-III-R and codes F20, F22, and F23 in ICD-10) were recorded at follow-up.nnnRESULTSnEight-year cumulative risk to receive a schizophrenia spectrum diagnosis was 46% (95% CI, 35%-57%) for persons with a diagnosis of cannabis-induced psychosis and 30% (95% CI, 14%-46%) for those with an amphetamine-induced psychosis. Although alcohol-induced psychosis was the most common type of SIP, 8-year cumulative risk for subsequent schizophrenia spectrum diagnosis was only 5.0% (95% CI, 4.6%-5.5%). No differences were detected with regard to gender, except for amphetamine-induced psychosis, which converted into a schizophrenia spectrum disorder significantly more often in men (P = .04). The majority of conversions to a schizophrenia spectrum diagnosis occurred during the first 3 years following the index treatment period, especially for cannabis-induced psychosis.nnnCONCLUSIONnSubstance-induced psychotic disorders predict schizophrenia spectrum disorders to a greater extent than previously thought. The intensity of clinical attention focused on substance-induced psychotic disorders should be increased.

Seclusion and restraint in psychiatry: patients' experiences and practical suggestions on how to improve practices and use alternatives.

PURPOSEnThis study explored psychiatric inpatients experiences of, and their suggestions for, improvement of seclusion/restraint, and alternatives to their use in Finland.nnnMETHODSnThe data were collected by focused interviews (n= 30) and were analyzed with inductive content analysis.nnnRESULTSnPatients perspectives received insufficient attention during seclusion/restraint processes. Improvements (e.g., humane treatment) and alternatives (e.g., empathetic patient-staff interaction) to seclusion/restraint, as suggested by the patients, focused on essential parts of nursing practice but have not been largely adopted.nnnPRACTICE IMPLICATIONSnPatients basic needs have to be met, and patient-staff interaction has to also continue during seclusion/restraint. Providing patients with meaningful activities, planning beforehand, documenting the patients wishes, and making patient-staff agreements reduce the need for restrictions and offer alternatives for seclusion/restraint. Service users must be involved in all practical development.

Patient restrictions: Are there ethical alternatives to seclusion and restraint?

The use of patient restrictions (e.g. involuntary admission, seclusion, restraint) is a complex ethical dilemma in psychiatric care. The present study explored nurses’ (n = 22) and physicians’ (n = 5) perceptions of what actually happens when an aggressive behaviour episode occurs on the ward and what alternatives to seclusion and restraint are actually in use as normal standard practice in acute psychiatric care. The data were collected by focus group interviews and analysed by inductive content analysis. The participants believed that the decision-making process for managing patients’ aggressive behaviour contains some in-built ethical dilemmas. They thought that patients’ subjective perspective received little attention. Nevertheless, the staff proposed and appeared to use a number of alternatives to minimize or replace the use of seclusion and restraint. Medical and nursing staff need to be encouraged and taught to: (1) tune in more deeply to reasons for patients’ aggressive behaviour; and (2) use alternatives to seclusion and restraint in order to humanize patient care to a greater extent.

Personality disorders and psychoses form two distinct subgroups of homicide among female offenders

This study examined circumstances of homicide by women in relation to their subsequent diagnoses. We investigated the written reports of forensic psychiatric examinations on 125 Finnish women who committed murder, attempted murder, manslaughter, or attempted manslaughter during 1982-92. In 86% of the cases the victims were adults, in 15% children. Intimate partners were the victims in 54% of the cases. Stabbing was the most frequent method and a quarrel the most frequent motive. The diagnoses of personality disorders and psychoses formed distinct subgroups. Psychotic women attacked proportionally more children than the personality disordered, who mainly attacked adults. Personality disordered women were more likely to have been intoxicated with alcohol at the time. Future treatment programmes and studies are suggested.

Gender differences in filicide offense characteristics--a comprehensive register-based study of child murder in two European countries.

OBJECTIVEnThis study searched for gender differences in filicidal offense characteristics and associated variables.nnnMETHODSnIn this bi-national register-based study all filicide perpetrators (75 mothers and 45 fathers) and their crimes in Austria and Finland 1995-2005 were examined for putative gender differences. The assessed variables were associated with the offense characteristics, the offenders socioeconomic and criminal history, and related stressful events.nnnRESULTSnMothers had previously committed violent offenses less often than fathers (5% vs. 28%, p<0.001) and they were less often employed (27% vs. 49%, p<0.05). Mothers victims were on average younger than those of fathers; median ages of the victims were 3.4 and 6.1 years, respectively (p<0.001). Fathers were more often intoxicated during the offense (11% vs. 42%, p<0.001) and also used shooting as the method of operation more often than mothers (5% vs. 27%, p<0.001). Mothers used drowning, criminal negligence, and poisoning more often than fathers. Fathers motives were more impulsive in nature (13% vs. 41%, p<0.001). After the killing, mothers tried to get rid of the body more often than fathers (25% vs. 7%, p<0.05).nnnCONCLUSIONSnFathers who commit filicide may represent at least two subgroups, the one not unlike the common homicide offender; the other, the overloaded, working and suicidal father. Mothers may include several types of offenders, one of which is the neonaticide offender. More detailed descriptions and, therefore, more research are needed.nnnPRACTICE IMPLICATIONSnDistressed parents and families need support and health care personnel, social work and other officials need to be alert to notice fatigued parents signs of despair, especially when several stressful experiences amass. Straightforward enquiry to the situation and even practical and psychological help may be needed for enhanced protection of children. The role of employers should also be discussed in relation to the welfare of working parents.

Finnish female homicide offenders 1982–92

Abstract Female homicide has been associated with several psychiatric disorders. This distinct field seems to be in need of more research, and therefore we wanted to explore the homicidal women of Finland. We studied written reports of forensic psychiatric evaluations of female offenders committing homicide or attempted homicide during the years 1982–92. Of the investigated women, 28.0% were diagnosed with a psychotic illness, 43.9% with alcoholism and 72.0% with a personality disorder. Comorbidity was common. Only 38.6% of the studied women had a single diagnosis. Those diagnosed as psychotic were not considered legally responsible for their acts. Most offenders had had previous psychiatric care. All the women committing neonaticidc were diagnosed with a personality disorder and none was deemed fully responsible for her act. Further analyses with a new study design might elucidate the characteristic homicidal woman.

Psychopathic traits and offender characteristics – a nationwide consecutive sample of homicidal male adolescents

BackgroundThe aim of the study was to evaluate psychopathy-like personality traits in a nationwide consecutive sample of adolescent male homicide offenders and to compare the findings with those of a randomly sampled adult male homicide offender group. A further aim was to investigate associations between psychopathic traits and offender and offence characteristics in adolescent homicides.MethodsForensic psychiatric examination reports and crime reports of all 15 to19- year- old male Finnish offenders who had been subjected to a forensic psychiatric examination and convicted for a homicide during 1995–2004 were collected (n = 57). A random sample of 57 adult male homicide offenders was selected as a comparison group. Offence and offender characteristics were collected from the files and a file-based assessment of psychopathic traits was performed using the Hare Psychopathy Checklist-Revised (PCL-R) by trained raters.ResultsNo significant differences existed between the adolescents and adults in PCL-R total scores, factor 2 (social deviance) scores, or in facets 3 (lifestyle) and 4 (antisocial). Adults scored significantly higher on factor 1 (interpersonal/affective) and facets 1 (interpersonal) and 2 (affective). The adolescent group was divided into two subgroups according to PCL-R total scores. One in five homicidal male adolescents met criteria for psychopathic personality using a PCL-R total score of 26 or higher. These boys significantly more often had a crime history before the index homicide, more frequently used excessive violence during the index homicide, more rarely lived with both parents until 16 years of age, had more institutional or foster home placements in childhood, had more school difficulties, more often had received special education, and, more often had contact with mental health services prior to age 18 years than boys scoring low on the PCL-R. They also more often had parental criminal history as well as homicide history of parents or near relatives than the group scoring low on the PCL-R.ConclusionHomicidal boys behaved as antisocially as the homicidal adults. The adults, however, showed more both affective and interpersonal features of psychopathy. Homicidal adolescents with psychopathy-like personality character form a special subgroup among other homicidal youngsters. Recognizing their characteristics, especially in life course development, would facilitate effective prevention and intervention efforts.

Gender-Specific Risk Factors for Intimate Partner Homicide: A Nationwide Register-Based Study

The present study examined gender differences in intimate partner homicide (IPH) and offender characteristics with the focus on putative gender-specific risk factors in a nationwide consecutive sample of homicide offenders. Data on all offenders (N = 642; 91 females, 551 males) convicted of homicide and subjected to a forensic psychiatric examination in Finland were obtained for the years 1995 and 2004. IPH offenders, 39 female and 106 male, were compared for risk factors with female and male offenders whose victims were not spouses. The forensic psychiatric examination reports were retrospectively analyzed, and the Hare Psychopathy Checklist–Revised (PCL-R) was rated. Significant gender differences were found in four risk factors: employment, intoxication of victim, self-defense, and quarrel, mostly related to alcohol as a factor of the offense. The findings support the notion that female IPH is linked to defensive reactions resulting from prior abuse, and that IPH offenders resemble the general population more than offenders of other types of homicide.

Examination of psychopathy in female homicide offenders--confirmatory factor analysis of the PCL-R.

The construct of psychopathy is essential in explaining criminal behavior, but unfortunately the empirical research on psychopathy in women has been inconsistent. In this study the underlying structure of psychopathy in women was examined by testing the two-factor model by Hare (2003) and the three-factor solution by Cooke and Michie (2001) using confirmatory factor analysis. We replicated the study by Warren et al. (2003) using a nationwide sample of 97 female homicide offenders in order to facilitate the comparison of results. The prevalence of psychopathy in the present study was 9.3% with a cut-off of >or=30 and 21.6% with a cut-off of >or=25. The best fit for the data out of the tested models was the three-factor model with six testlets. The two-factor model proved to be too simple a model for the female homicide data. The findings regarding comorbidity of psychopathy with personality disorders show that the concept of psychopathy includes diagnostic criteria of several personality disorders, but further research is needed to establish a possible superordinate dimension. Further research on the PCL-R and putative gender differences in the expression of psychopathy in women and men as well as on the putative impact of cultural differences on the instrument is clearly needed.

Secluded and restrained patients' perceptions of their treatment

Though some empirical and anecdotal accounts can be located in the extant literature, it remains the case that little is known about how secluded/restrained (S/R) patients perceive their overall treatment. The purpose of this study was to explore patients perceptions of their hospital treatment measured after S/R. The data were collected with a Secluded and Restrained Patients Perceptions of their Treatment (S/R-PPT) questionnaire from S/R patients aged 18-65 years. Ninety completed questionnaires were analysed. Patients perceived that they received enough attention from staff, and they were able to voice their opinions, but their opinions were not taken into account. Patients denied the necessity and beneficence of S/R. Women and older patients were more critical than men and younger patients regarding the use of restrictions. There were also statistically-significant differences in responses among patients at different hospitals. It is concluded that patients opinions need more attention in treatment decisions. To achieve this, psychiatric treatment needs genuine dialogue between patients and staff, and individual care should have alternatives and no routine decisions. Therefore, the treatment culture must improve towards involving patients in treatment planning, and giving them a say when S/R is considered.