Niklas Långström

Schizophrenia, substance abuse, and violent crime.

CONTEXT Persons with schizophrenia are thought to be at increased risk of committing violent crime 4 to 6 times the level of general population individuals without this disorder. However, risk estimates vary substantially across studies, and considerable uncertainty exists as to what mediates this elevated risk. Despite this uncertainty, current guidelines recommend that violence risk assessment should be conducted for all patients with schizophrenia. OBJECTIVE To determine the risk of violent crime among patients diagnosed as having schizophrenia and the role of substance abuse in mediating this risk. DESIGN, SETTING, AND PARTICIPANTS Longitudinal designs were used to link data from nationwide Swedish registers of hospital admissions and criminal convictions in 1973-2006. Risk of violent crime in patients after diagnosis of schizophrenia (n = 8003) was compared with that among general population controls (n = 80 025). Potential confounders (age, sex, income, and marital and immigrant status) and mediators (substance abuse comorbidity) were measured at baseline. To study familial confounding, we also investigated risk of violence among unaffected siblings (n = 8123) of patients with schizophrenia. Information on treatment was not available. MAIN OUTCOME MEASURE Violent crime (any criminal conviction for homicide, assault, robbery, arson, any sexual offense, illegal threats, or intimidation). RESULTS In patients with schizophrenia, 1054 (13.2%) had at least 1 violent offense compared with 4276 (5.3%) of general population controls (adjusted odds ratio [OR], 2.0; 95% confidence interval [CI], 1.8-2.2). The risk was mostly confined to patients with substance abuse comorbidity (of whom 27.6% committed an offense), yielding an increased risk of violent crime among such patients (adjusted OR, 4.4; 95% CI, 3.9-5.0), whereas the risk increase was small in schizophrenia patients without substance abuse comorbidity (8.5% of whom had at least 1 violent offense; adjusted OR, 1.2; 95% CI, 1.1-1.4; P<.001 for interaction). The risk increase among those with substance abuse comorbidity was significantly less pronounced when unaffected siblings were used as controls (28.3% of those with schizophrenia had a violent offense compared with 17.9% of their unaffected siblings; adjusted OR, 1.8; 95% CI, 1.4-2.4; P<.001 for interaction), suggesting significant familial (genetic or early environmental) confounding of the association between schizophrenia and violence. CONCLUSIONS Schizophrenia was associated with an increased risk of violent crime in this longitudinal study. This association was attenuated by adjustment for substance abuse, suggesting a mediating effect. The role of risk assessment, management, and treatment in individuals with comorbidity needs further examination.

Mental Disorders Among Adolescents in Juvenile Detention and Correctional Facilities: A Systematic Review and Metaregression Analysis of 25 Surveys

OBJECTIVE To systematically review and perform a meta-analysis of the research literature on the prevalence of mental disorders in adolescents in juvenile detention and correctional facilities. METHOD Surveys of psychiatric morbidity based on interviews of unselected populations of detained children and adolescents were identified by computer-assisted searches, scanning of reference lists, hand-searching of journals, and correspondence with authors of relevant reports. The sex-specific prevalence of mental disorders (psychotic illness, major depression, attention-deficit/hyperactivity disorder [ADHD], and conduct disorder) together with potentially moderating study characteristics were abstracted from publications. Statistical analysis involved metaregression to identify possible causes of differences in disorder prevalence across surveys. RESULTS Twenty-five surveys involving 13,778 boys and 2,972 girls (mean age 15.6 years, range 10-19 years) met inclusion criteria. Among boys, 3.3% (95% confidence interval [CI] 3.0%-3.6%) were diagnosed with psychotic illness, 10.6% (7.3%-13.9%) with major depression, 11.7% (4.1%-19.2%) with ADHD, and 52.8% (40.9%-64.7%) with conduct disorder. Among girls, 2.7% (2.0%-3.4%) were diagnosed with psychotic illness, 29.2% (21.9%-36.5%) with major depression, 18.5% (9.3%-27.7%) with ADHD, and 52.8% (32.4%-73.2%) with conduct disorder. Metaregression suggested that surveys using the Diagnostic Interview Schedule for Children yielded lower prevalence estimates for depression, ADHD, and conduct disorder, whereas studies with psychiatrists acting as interviewers had lower prevalence estimates only of depression. CONCLUSIONS Adolescents in detention and correctional facilities were about 10 times more likely to suffer from psychosis than the general adolescent population. Girls were more often diagnosed with major depression than were boys, contrary to findings from adult prisoners and general population surveys. The findings have implications for the provision of psychiatric services for adolescents in detention.

Risk of suicide after suicide attempt according to coexisting psychiatric disorder: Swedish cohort study with long term follow-up

Objective To investigate the impact of coexistent psychiatric morbidity on risk of suicide after a suicide attempt. Design Cohort study with follow-up for 21-31 years. Setting Swedish national register based study. Participants 39 685 people (53% women) admitted to hospital for attempted suicide during 1973-82. Main outcome measure Completed suicide during 1973-2003. Results A high proportion of suicides in all diagnostic categories took place within the first year of follow-up (14-64% in men, 14-54% in women); the highest short term risk was associated with bipolar and unipolar disorder (64% in men, 42% in women) and schizophrenia (56% in men, 54% in women). The strongest psychiatric predictors of completed suicide throughout the entire follow-up were schizophrenia (adjusted hazard ratio 4.1, 95% confidence interval 3.5 to 4.8 in men, 3.5, 2.8 to 4.4 in women) and bipolar and unipolar disorder (3.5, 3.0 to 4.2 in men, 2.5, 2.1 to 3.0 in women). Increased risks were also found for other depressive disorder, anxiety disorder, alcohol misuse (women), drug misuse, and personality disorder. The highest population attributable fractions for suicide among people who had previously attempted suicide were found for other depression in women (population attributable fraction 9.3), followed by schizophrenia in men (4.6), and bipolar and unipolar disorder in women and men (4.1 and 4.0, respectively). Conclusion Type of psychiatric disorder coexistent with a suicide attempt substantially influences overall risk and temporality for completed suicide. To reduce this risk, high risk patients need aftercare, especially during the first two years after attempted suicide among patients with schizophrenia or bipolar and unipolar disorder.

Method of attempted suicide as predictor of subsequent successful suicide: national long term cohort study

Objective To study the association between method of attempted suicide and risk of subsequent successful suicide. Design Cohort study with follow-up for 21-31 years. Setting Swedish national register linkage study. Participants 48 649 individuals admitted to hospital in 1973-82 after attempted suicide. Main outcome measure Completed suicide, 1973-2003. Multiple Cox regression modelling was conducted for each method at the index (first) attempt, with poisoning as the reference category. Relative risks were expressed as hazard ratios with 95% confidence intervals. Results 5740 individuals (12%) committed suicide during follow-up. The risk of successful suicide varied substantially according to the method used at the index attempt. Individuals who had attempted suicide by hanging, strangulation, or suffocation had the worst prognosis. In this group, 258 (54%) men and 125 (57%) women later successfully committed suicide (hazard ratio 6.2, 95% confidence interval 5.5 to 6.9, after adjustment for age, sex, education, immigrant status, and co-occurring psychiatric morbidity), and 333 (87%) did so with a year after the index attempt. For other methods (gassing, jumping from a height, using a firearm or explosive, or drowning), risks were significantly lower than for hanging but still raised at 1.8 to 4.0. Cutting, other methods, and late effect of suicide attempt or other self inflicted harm conferred risks at levels similar to that for the reference category of poisoning (used by 84%). Most of those who successfully committed suicide used the same method as they did at the index attempt—for example, >90% for hanging in men and women. Conclusion The method used at an unsuccessful suicide attempt predicts later completed suicide, after adjustment for sociodemographic confounding and psychiatric disorder. Intensified aftercare is warranted after suicide attempts involving hanging, drowning, firearms or explosives, jumping from a height, or gassing.

Medication for Attention Deficit–Hyperactivity Disorder and Criminality

BACKGROUND Attention deficit-hyperactivity disorder (ADHD) is a common disorder that has been associated with criminal behavior in some studies. Pharmacologic treatment is available for ADHD and may reduce the risk of criminality. METHODS Using Swedish national registers, we gathered information on 25,656 patients with a diagnosis of ADHD, their pharmacologic treatment, and subsequent criminal convictions in Sweden from 2006 through 2009. We used stratified Cox regression analyses to compare the rate of criminality while the patients were receiving ADHD medication, as compared with the rate for the same patients while not receiving medication. RESULTS As compared with nonmedication periods, among patients receiving ADHD medication, there was a significant reduction of 32% in the criminality rate for men (adjusted hazard ratio, 0.68; 95% confidence interval [CI], 0.63 to 0.73) and 41% for women (hazard ratio, 0.59; 95% CI, 0.50 to 0.70). The rate reduction remained between 17% and 46% in sensitivity analyses among men, with factors that included different types of drugs (e.g., stimulant vs. nonstimulant) and outcomes (e.g., type of crime). CONCLUSIONS Among patients with ADHD, rates of criminality were lower during periods when they were receiving ADHD medication. These findings raise the possibility that the use of medication reduces the risk of criminality among patients with ADHD. (Funded by the Swedish Research Council and others.).

Psychopathy (PCL-R) predicts violent recidivism among criminal offenders with personality disorders in Sweden

Psychopathy as conceptualized with Hares Psychopathy Checklist Revised, PCL-R, has attracted much research during the 1990s. In the Scandinavian countries, few studies that empirically support the validity of North American risk assessment techniques in our regional context have been published. The purpose of this paper is to explore the predictive power of the PCL-R in a population of personality-disordered violent offenders subjected to forensic psychiatric evaluation in Sweden. Following release from prison (n = 172), discharge from forensic psychiatric treatment (n = 129), or probation (n = 51), a total of 352 individuals were followed for up to 8 years (mean = 3.7 years) with reconviction for violent crime as endpoint variable (base rate 34%). As the estimate of predictive power, the area under the curve of a receiver operating characteristic (AUC of ROC) analysis was calculated. For PCL-R scores to predict 2-year violent recidivism, AUC of ROC was .72 (95% CI: .66–.78). In addition, the personality dimension of psychopathy (Factor 1) and the behavioral component (Factor 2) both predicted 2-year recidivism significantly better than random: AUC of ROC .64 (95% CI: .57–.70) and .71 (95% CI: .65–.77), respectively. We conclude that psychopathy is probably as valid a predictor of violent recidivism in Swedish forensic settings as seen in previous North American studies.

Advancing Paternal Age and Bipolar Disorder

CONTEXT Advancing paternal age has been reported as a risk factor for neurodevelopmental disorders. OBJECTIVES To determine whether advanced paternal age is associated with an increased risk of BPD in the offspring and to assess if there was any difference in risk when analyzing patients with early-onset BPD separately. DESIGN A nationwide nested case-control study based on Swedish registers was performed. Risk for BPD in the offspring of older fathers was estimated using conditional logistic regression analysis controlling for potential confounding of parity, maternal age, socioeconomic status, and parental family history of psychotic disorders. SETTING Identification of 7,328,100 individuals and their biological parents by linking the nationwide Multigeneration Register and the Hospital Discharge Register. PARTICIPANTS A total of 13,428 patients with a BPD diagnosis on at least 2 separate hospital admissions was identified. Five healthy control subjects matched for sex and year of birth were randomized to each case. Main Outcome Measure Bipolar disorder based on ICD codes at discharge from hospital treatment. RESULTS An association between paternal age and risk for BPD in the offspring of older men was noted. The risk increased with advancing paternal age. After controlling for parity, maternal age, socioeconomic status, and family history of psychotic disorders, the offspring of men 55 years and older were 1.37 (95% confidence interval [CI], 1.02-1.84) times more likely to be diagnosed as having BPD than the offspring of men aged 20 to 24 years. The maternal age effect was less pronounced. For early-onset (<20 years) cases, the effect of paternal age was much stronger (odds ratio, 2.63; 95% CI, 1.19-5.81), whereas no statistically significant maternal age effect was found. CONCLUSIONS Advanced paternal age is a risk factor for BPD in the offspring. The results are consistent with the hypothesis that advancing paternal age increases the risk for de novo mutations in susceptibility genes for neurodevelopmental disorders.

Long-term follow-up of transsexual persons undergoing sex reassignment surgery: Cohort study in Sweden

Context The treatment for transsexualism is sex reassignment, including hormonal treatment and surgery aimed at making the persons body as congruent with the opposite sex as possible. There is a dearth of long term, follow-up studies after sex reassignment. Objective To estimate mortality, morbidity, and criminal rate after surgical sex reassignment of transsexual persons. Design A population-based matched cohort study. Setting Sweden, 1973-2003. Participants All 324 sex-reassigned persons (191 male-to-females, 133 female-to-males) in Sweden, 1973–2003. Random population controls (10∶1) were matched by birth year and birth sex or reassigned (final) sex, respectively. Main Outcome Measures Hazard ratios (HR) with 95% confidence intervals (CI) for mortality and psychiatric morbidity were obtained with Cox regression models, which were adjusted for immigrant status and psychiatric morbidity prior to sex reassignment (adjusted HR [aHR]). Results The overall mortality for sex-reassigned persons was higher during follow-up (aHR 2.8; 95% CI 1.8–4.3) than for controls of the same birth sex, particularly death from suicide (aHR 19.1; 95% CI 5.8–62.9). Sex-reassigned persons also had an increased risk for suicide attempts (aHR 4.9; 95% CI 2.9–8.5) and psychiatric inpatient care (aHR 2.8; 95% CI 2.0–3.9). Comparisons with controls matched on reassigned sex yielded similar results. Female-to-males, but not male-to-females, had a higher risk for criminal convictions than their respective birth sex controls. Conclusions Persons with transsexualism, after sex reassignment, have considerably higher risks for mortality, suicidal behaviour, and psychiatric morbidity than the general population. Our findings suggest that sex reassignment, although alleviating gender dysphoria, may not suffice as treatment for transsexualism, and should inspire improved psychiatric and somatic care after sex reassignment for this patient group.

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.

Risk for Criminal Recidivism Among Young Sex Offenders

Several authors have emphasized the need for empirically derived instruments for reoffending risk assessment among young sex offenders (YSOs). The authors screened the literature on sex offenders for clinically or empirically motivated variables related to criminal recidivism, identifying 22 putative risk factors. All Swedish YSOs (aged 15-20) subjected to court-ordered forensic psychiatric investigations from 1988 through 1995 and available for follow-up (n = 46) were included (mean time at risk = 5 years). Base rates for sexual and general recidivism were 20% and 65%, respectively. Previous criminality, early onset conduct disorder, psychopathy, and use of death threats and weapons at index sex crime proved predictive of general but not sexual recidivism. Factors indicative of sexual deviance (early onset sexually abusive behavior, male victim choice, more than one victim) and poor social skills were associated with elevated risk for sexual reoffending. However, replication in independent samples is needed to corroborate these preliminary findings.