Stephen Allnutt

Mental health status of Aboriginal and non-Aboriginal Australian prisoners

Objective: To compare the mental health of Aboriginal and non-Aboriginal prisoners in New South Wales. Methods: The sample consisted of a cross-sectional random sample of sentenced prisoners, and a consecutive sample of reception prisoners. The sample was drawn from 29 correctional centres (27 male, two female) across New South Wales. Overall, 1208 men (226 Aboriginal), and 262 women (51 Aboriginal) participated in the study. Mental illness was detected using the Composite International Diagnostic Interview (CIDI-A) and a number of other screening measures incorporated into the programme. Results: No differences were detected in mental illness between Aboriginal and non-Aboriginal men, apart from depression, which was lower in the latter group. Aboriginal woman were more likely than non-Aboriginal women to screen positive for symptoms of psychosis in the prior 12 months and have a higher 1 month and 12 month prevalence of affective disorder; they also had higher psychological distress scores. Suicidal thoughts and attempts were the same in both groups. Conclusions: These findings confirm that the demand for mental health services in prisons is considerable, and that Aboriginal women are one of the most vulnerable groups. Services and programmes providing an alternative to incarceration are needed, as are culturally sensitive approaches to treatment.

Co-morbidity of alcoholism and the paraphilias.

Alcoholism has been related to a wide variety of crimes. Various authors have studied the prevalence of alcoholism in relationship to incest, rape and pedophilia. This study evaluates the co-morbidity of alcoholism and the specific paraphilias including sexual sadism, fetishism, incest, pedophilia, exhibitionism and transvestism. Rapists were included although by definition it is not strictly a paraphilic disorder. Seven hundred and twenty eight paraphilic individuals were evaluated. More than 50% of sexual sadists were alcoholics. Alcoholism in association with sexual sadists was statistically significant as compared to transvestites, rapists, pedophiles, and incest offenders. Transvestism had the lowest relative rate of alcoholism. The authors discuss these findings and the role alcoholism plays in causing violent sexual behavior in individuals with paraphilias.

General principles of forensic report writing

Objective: The aim of this paper is to provide an update of principles of forensic report writing, to guide and assist registrars, junior consultants and psychiatrists considering working within the forensic arena. Method: The literature was reviewed for information on principles of report writing from a variety of jurisdictions. Additionally, literature on medical ethics was examined. Result: Writing reports is a professional activity that most psychiatrists undertake at some point in their careers. The report represents the psychiatrists professional opinion. It is important that information is accurate, relevant and ethical. In writing medico-legal reports, psychiatry deviates from traditional medical ethics. Conclusion: It is important that psychiatrists who write reports have a good understanding of the process and behave ethically and competently.

Reducing impulsivity in repeat violent offenders: an open label trial of a selective serotonin reuptake inhibitor

Background: The association between serotonergic dysfunction and aggression has prompted the use of selective serotonin re-uptake inhibitors (SSRIs) as a means of controlling impulsive violent behaviour. The aim of the current study was to examine the feasibility of using an SSRI to treat impulsivity in a group of repeat violent offenders. Methods: Potential participants were recruited from three magistrates’ court complexes in the Sydney metropolitan area and all had histories of violent offending (at least one prior conviction for a violent offence). Those who scored highly on the Barratt Impulsivity Scale (BIS-11), passed medical and psychiatric evaluations and consented to treatment were prescribed sertraline (Zoloft) over a three month period. Results: Thirty-four individuals commenced the trial, with 20 completing the three month intervention. Reductions were observed across a range of behavioural measures from baseline to 3 months: impulsivity (35%), irritability (45%), anger (63%), assault (51%), verbal-assault (40%), indirect-assault (63%), and depression (62%). All those who completed the three month trial requested to continue sertraline under the supervision of their own medical practitioner. Conclusion: Our findings suggest that treating impulsive violent individuals in the criminal justice system with an SSRI is a potential treatment opportunity for this population. An adequately powered randomized control trial of this intervention is warranted.

Temperament, substance use and psychopathology in a prisoner population: implications for treatment.

Objective: The association between temperament and drug use or temperament and psychopathology has previously been restricted to community clinical or non-clinical samples. The aim of the present study was therefore to examine these associations in a large cohort of Australian offenders using Cloningers Temperament and Character Inventory (TCI). Methods: A total of 1322 prisoners from New South Wales (NSW) who completed all dimensions of the TCI and were screened for mental illness using the Australian National Survey of Mental Health and Wellbeing were included in the study. Results: A total of 15% of the sample fulfilled the criteria for a diagnosis for depression, 36% for anxiety disorders and 54% for a substance abuse disorder. Using logistic regression analysis, the TCI dimensions of harm-avoidance and low self-direction predicted depression. Being female, a poly-substance user and having high harm-avoidance, persistence, self-direction and self-transcendence predicted anxiety disorders. Significant stepped trends across age, gender, and type of drug use were found for all TCI dimensions. Conclusions: The TCI is useful in identifying prisoners with a history of psychopathology and substance misuse. This tool also provides clinically relevant information about at-risk individuals and has the potential to guide the development of intervention programmes for inmates.

Pursuit of the perfect mother: an unusual case of stalking

Objective: To highlight issues of adoption and twinship in an unusual case of stalking. Clinical picture: An ususual case of same gender, serial stalking which began at an early age in a young woman who was one of a set of twins adopted at birth. Treatment: Insight orientated psychotherapy. Outcome: Beneficial outcome in context of clear boundaries, therapist selection and emphasis upon legal consequences of behaviour. Conclusions: Early disruptions to attachments including adoption and twinship may have relevance in some patterns of adult stalking behaviour.

The harassment and stalking of plastic surgeons by their patients in Australasia

Medical professionals come into direct contact with the public. The relationships are often personal. The aim of the survey is to examine the prevalence of harassment of plastic surgeons by their patients.

Managing aggression and violence: the clinician's role in contemporary mental health care.

Objective: From time to time misconceptions about violence risk assessment raise debate about the role mental health professionals play in managing aggression, with associated concerns about the utility of violence risk assessment. This paper will address some of the misconceptions about risk assessment in those with serious mental illness. Methods: The authors have expertise as clinicians and researchers in the field and based on their accumulated knowledge and discussion they have reviewed the literature to form their opinions. Results: This paper reflects the authors’ views. Conclusion: There is a modest yet statistical and clinically significant association between certain types of mental illness and violence. Debate about the appropriateness of clinician involvement in violence risk assessment is sometimes based on a misunderstanding about the central issues and the degree to which this problem can be effectively managed. The central purpose of risk assessment is the prevention rather than the prediction of violence. Violence risk assessment is a process of identifying patients who are at greater risk of violence in order to facilitate the timing and prioritisation of preventative interventions. Clinicians should base these risk assessments on empirical knowledge and consideration of case-specific factors to inform appropriate management interventions to reduce the identified risk.

Mentally ill prisoners in Australia have poor physical health

Our objective was to compare the physical health status of adult prisoners with and without a mental illness. Mental illness was diagnosed in a sample of 557 Australian prisoners using the Composite International Diagnostic Interview (CIDI). Physical health measures included self‐reported chronic health conditions, recent health complaints and symptoms, self‐assessed health using the Short‐Form 36 Health Survey (SF‐36), and markers of infectious diseases known to be highly prevalent among prisoner populations (hepatitis A, hepatitis B, and hepatitis C). Men and women with a mental illness had lower scores on the SF‐36 compared with those without a mental illness indicating poor overall health. Adjusting for age and sex, a diagnosis of any mental illness (symptoms of psychosis, anxiety or affective disorder) was positively associated with a history of head injury, back problems, asthma, peptic ulcers, cancer, and epilepsy/seizures. There was a significant association between post traumatic stress disorder and asthma, a history of head injury, peptic ulcers, and cancer. There was no significant difference in the proportion of current tobacco smokers in the mentally ill and nonmentally ill groups (81% vs. 77%, p = 0.33). However, those with a mental illness were less likely than those with no diagnosis to exercise in the past 4 weeks (79% vs. 89%, p = 0.002). Mentally ill prisoners also have significant physical co‐morbidity compared with the non‐mentally ill. These findings suggest that those providing mental health services to prisoners should adopt a holistic approach embracing both mental and physical health.

When killing isn't murder: psychiatric and psychological defences to murder when the insanity defence is not applicable

Objective: This paper describes psychiatric and psychological defences to murder where the defence of insanity is not applicable. The charges of murder and manslaughter are outlined. Self-defence, sane and insane automatism, provocation, diminished responsibility, duress, necessity and novel defences are discussed. Conclusions: The complexities of psychological and psychiatric expert evidence are highlighted as well as the fact that legal decisions are not always consistent with medical or scientific theory. It is concluded that this is a controversial and evolving area of mental health law and mental health professionals have an educative role and a responsibility to provide testimony that is supported by the best possible evidence.