Thomas Fahy

Intensive versus standard case management for severe psychotic illness: a randomised trial

BACKGROUND Case management has increasingly been the recommended approach to care for severely mentally ill patients since the number of psychiatric beds has decreased. Despite equivocal results, in the UK and Europe, this approach is becoming accepted policy. We assessed the effect of smaller case loads. METHODS We randomly assigned 708 psychotic patients in four centres standard case management (355 patients, case load 30-35 per case manager) or intensive case management (353 patients, case load 10-15 per case manager). We measured clinical symptoms and social functioning at baseline, 1 year, and 2 years. The impact of treatment on hospital use was assessed at 2 years by subgroup analyses for Afro-Caribbean and for severely socially disabled patients. Analysis was by intention to treat. FINDINGS There was no significant decline in overall hospital use among intensive-case-management patients (mean 73.5 vs 73.1 days in those who received standard care [SD 0.4, 95% CI -17.4 to 18.1]), nor were there any significant gains in clinical or social functioning. There was no evidence of differential effect in Afro-Caribbean patients or the most socially disabled patients. INTERPRETATION In well-coordinated mental-health services, a decline in case load alone does not improve outcome for these patients. Mental-health planners may need to pay more attention to the content of treatment rather than changes in service organisation.

Altered connections on the road to psychopathy

Psychopathy is strongly associated with serious criminal behaviour (for example, rape and murder) and recidivism. However, the biological basis of psychopathy remains poorly understood. Earlier studies suggested that dysfunction of the amygdala and/or orbitofrontal cortex (OFC) may underpin psychopathy. Nobody, however, has ever studied the white matter connections (such as the uncinate fasciculus (UF)) linking these structures in psychopaths. Therefore, we used in vivo diffusion tensor magnetic resonance imaging (DT-MRI) tractography to analyse the microstructural integrity of the UF in psychopaths (defined by a Psychopathy Checklist Revised (PCL-R) score of ⩾25) with convictions that included attempted murder, manslaughter, multiple rape with strangulation and false imprisonment. We report significantly reduced fractional anisotropy (FA) (P<0.003), an indirect measure of microstructural integrity, in the UF of psychopaths compared with age- and IQ-matched controls. We also found, within psychopaths, a correlation between measures of antisocial behaviour and anatomical differences in the UF. To confirm that these findings were specific to the limbic amygdala–OFC network, we also studied two ‘non-limbic’ control tracts connecting the posterior visual and auditory areas to the amygdala and the OFC, and found no significant between-group differences. Lastly, to determine that our findings in UF could not be totally explained by non-specific confounds, we carried out a post hoc comparison with a psychiatric control group with a past history of drug abuse and institutionalization. Our findings remained significant. Taken together, these results suggest that abnormalities in a specific amygdala–OFC limbic network underpin the neurobiological basis of psychopathy.

Psychopathological syndromes in the functional psychoses : associations with course and outcome

The aim of this study was to identify underlying dimensions of psychopathology in a cohort of patients with functional psychosis of recent onset, and to examine their prognostic value. Factor analysis of the psychopathological features of 166 consecutively admitted patients with functional psychosis of recent onset revealed seven psychopathological dimensions, which explained 63% of the variance. Five of these seven syndromes bore differential associations with subsequent treatment and illness course, independent of: (i) associations with DSM-III-R diagnosis; (ii) associations with other prognostic factors; and (iii) associations with the baseline values of outcome variables. The most striking associations were shown for an early and insidious onset syndrome with affective flattening, which predicted a more disabled course of illness on three of four outcome dimensions, and which was more common in males and unmarried individuals. A second syndrome, characterized by bizarre behaviour, inappropriate affect, catatonia, and poor rapport showed similar, slightly less striking, associations with illness course, as well as with poor pre-morbid social functioning. A third syndrome, characterized by positive psychotic symptoms was to a lesser degree associated with poorer outcome, whereas a fourth syndrome distinguished by manic symptomatology predicted a more benign illness course. A fifth syndrome identified by lack of insight predicted more time in hospital and admission under a section of the Mental Health Act during the follow-up period. A further finding was that dimensional representations of psychopathological features were considerably more useful than categorical representations (DSM-III-R and ICD-10) as predictors of illness course and treatment decisions.

Violent offending by UK military personnel deployed to Iraq and Afghanistan: a data linkage cohort study

BACKGROUND Violent offending by veterans of the Iraq and Afghanistan conflicts is a cause for concern and there is much public debate about the proportion of ex-military personnel in the criminal justice system for violent offences. Although the psychological effects of conflict are well documented, the potential legacy of violent offending has yet to be ascertained. We describe our use of criminal records to investigate the effect of deployment, combat, and post-deployment mental health problems on violent offending among military personnel relative to pre-existing risk factors. METHODS In this cohort study, we linked data from 13,856 randomly selected, serving and ex-serving UK military personnel with national criminal records stored on the Ministry of Justice Police National Computer database. We describe offending during the lifetime of the participants and assess the risk factors for violent offending. FINDINGS 2,139 (weighted 17.0%) of 12,359 male UK military personnel had a criminal record for any offence during their lifetime. Violent offenders (1,369 [11.0%]) were the most prevalent offender types; prevalence was highest in men aged 30 years or younger (521 [20.6%] of 2,728) and fell with age (164 [4.7%] of 3027 at age >45 years). Deployment was not independently associated with increased risk of violent offending, but serving in a combat role conferred an additional risk, even after adjustment for confounders (violent offending in 137 [6.3%] of 2178 men deployed in a combat role vs 140 (2.4%) of 5,797 deployed in a non-combat role; adjusted hazard ratio 1.53, 95% CI 1.15-2.03; p=0.003). Increased exposure to traumatic events during deployment also increased risk of violent offending (violent offending in 104 [4.1%] of 2753 men with exposure to two to four traumatic events vs 56 [1.6%] of 2944 with zero to one traumatic event, 1.77, 1.21-2.58, p=0.003; and violent offending in 122 [5.1%] of 2582 men with exposure to five to 16 traumatic events, 1.65, 1.12-2.40, p=0.01; test for trend, p=0.032). Violent offending was strongly associated with post-deployment alcohol misuse (violent offending in 120 [9.0%] of 1363 men with alcohol misuse vs 155 [2.3%] of 6768 with no alcohol misuse; 2.16, 1.62-2.90; p<0.0001), post-traumatic stress disorder (violent offending in 25 [8.6%] of 344 men with post-traumatic stress disorder vs 221 [3.0%] of 7256 with no symptoms of post-traumatic stress disorder; 2.20, 1.36-3.55; p=0.001), and high levels of self-reported aggressive behaviour (violent offending in 56 [6.7%] of 856 men with an aggression score of six to 16 vs 22 [1.2%] of 1685 with an aggression score of zero; 2.47, 1.37-4.46; p=0.003). Of the post-traumatic stress disorder symptoms, the hyperarousal cluster was most strongly associated with violent offending (2.01, 1.50-2.70; p<0.0001). INTERPRETATION Alcohol misuse and aggressive behaviour might be appropriate targets for interventions, but any action must be evidence based. Post-traumatic stress disorder, though less prevalent, is also a risk factor for violence, especially hyperarousal symptoms, so if diagnosed it should be appropriately treated and associated risk monitored. FUNDING Medical Research Council and the UK Ministry of Defence.

Chronic paranoid psychosis after misuse of MDMA ("ecstasy")

A 28 year old man was admitted after attempting to strangle his wife. He had been taking MDMA at weekends for 18 months. He had gradually increased his dose from two to 10 tablets a night and become suspicious that his wife was being unfaithful to him. He had checked on her movements, spied on her, and interrogated her and forced her to supply false confessions. Latterly he had supplemented his intake of MDMA with occasional doses of cocaine. He had stopped taking any drugs six weeks before his admission. He had experienced a brief paranoid psychosis eight years earlier after misusing amphetamines. His mother had suffered from schizophrenia. Examination of his mental state showed prominent delusions of infidelity. Routine investigations, computed tomography of the brain, and serological tests for hepatitis B virus and HIV yielded normal results. He refused to provide a specimen of urine for drug screening. Treatment with haloperidol resulted in gradual improvement and he was discharged. Over the next seven months he twice relapsed and required readmission despite refraining from further use of drugs. On each admission urine specimens yielded negative results on drug screening.

Predicting violence in schizophrenia: a prospective study

BACKGROUND People with schizophrenia are more violent than the general population, but this increased risk is attributable to the actions of a small subgroup. Identifying those at risk has become an essential part of clinical practice. AIMS To estimate the risk factors for assault in patients with schizophrenia. METHODS Two hundred seventy-one patients with schizophrenia were interviewed using an extensive battery of instruments. Assault was measured from multiple data sources over the next 2 years and criminal records were obtained. Multiple sociodemographic and clinical variables measured at baseline were examined as possible predictors of assault during follow-up. RESULTS Sixty-nine (25%) patients committed assault during the 2-year follow-up. The model that best predicted assault included a history of recent assault (OR 2.33, 95% CI 1.17-4.61), a previous violent conviction (OR 2.02, 95% CI 1.04-3.87), having received special education (OR 2.76, 95% CI 1.22-6.26) and alcohol abuse (OR 3.55, 95% CI 1.24-10.2). CONCLUSIONS Previously established risk factors including a history of violence and alcohol abuse are replicated in this study. Although low premorbid IQ did not predict violence, a need for special education did.

Psychosis with good prognosis in Afro-Caribbean people now living in the United Kingdom

Abstract Objectives: To compare the course and outcome of psychotic illness in a group of Afro-Caribbean patients resident in the United Kingdom and a group of white British patients. Design: Cohort study of consecutive admissions followed up for four years. Subjects: 113 patients with psychotic illness of recent onset admitted to two south London hospitals. Main outcome measures: Course of illness, history of self harm, social disability, treatment received, and hospital use adjusted for socioeconomic origin. Results: The Afro-Caribbean group spent more time in a recovered state during the follow up period (adjusted odds ratio 5.0; 95% confidence interval 1.7 to 14.5), were less likely to have had a continuous illness (0.3; 0.1 to 0.8), were less at risk of self harm (0.2; 0.1 to 0.8), and were less likely to have been prescribed antidepressant treatment (0.3; 0.1 to 0.9). There were no differences in hospital use, but the Afro-Caribbean group had more involuntary admissions (8.9; 2.1 to 35.6) and more imprisonments over the follow up period (9.2; 1.6 to 52.3). Conclusions: Afro-Caribbean patients in the United Kingdom have a better outcome after psychiatric illness than do white people. The combination of high incidence and more benign course of illness of psychotic illness in this group may be due, at least in part, to a greater exposure to precipitants in the social environment.

Reducing violence in severe mental illness: randomised controlled trial of intensive case management compared with standard care

Abstract Objectives: To establish whether intensive case management reduces violence in patients with psychosis in comparison with standard case management. Design: Randomised controlled trial with two year follow up. Setting: Four inner city community mental health services. Participants: 708 patients with established psychotic illness allocated at random to intervention (353) or control (355) group. Intervention: Intensive case management (caseload 10–15 per case manager) for two years compared with standard case management (30-35 per case manager). Main outcome measure: Physical assault over two years measured by interviews with patients and case managers and examination of case notes. Results: No significant reduction in violence was found in the intensive case management group compared with the control group (22.7% v 21.9%, P=0.86). Conclusions: Intensive case management does not reduce the prevalence of violence in psychotic patients in comparison with standard care. What is already known on this topic Psychosis and violence are known to be associated Community psychiatric interventions aimed at reducing the risk of violence have not been evaluated What this study adds Increasing the intensity of contact between patients and case managers does not reduce the prevalence of violent behaviour in patients with psychosis Younger age, learning difficulties, and a history of violence, drug misuse, and victimisation predict violent behaviour in psychotic patients

Predicting suicidal risk in schizophrenic and schizoaffective patients in a prospective two-year trial

BACKGROUND Enhanced ability to reliably identify risk factors for suicidal behavior permits more focused decisions concerning treatment interventions and support services, with potential reduction in lives lost to suicide. METHODS This study followed 980 patients at high risk for suicide in a multicenter prospective study for 2 years after randomization to clozapine or olanzapine. A priori predictors related to diagnosis, treatment resistance, and clinical constructs of disease symptoms were evaluated as possible predictors of subsequent suicide-related events. RESULTS Ten baseline univariate predictors were identified. Historical predictors were diagnosis of schizoaffective disorder, history or current use at baseline of alcohol or substance abuse, cigarette smoking, number of lifetime suicide attempts, and the number of hospitalizations in the previous 36 months to prevent suicide. Predictive clinical features included greater baseline scores on the InterSePT scale for suicidal thinking, the Covi Anxiety Scale, the Calgary Depression Scale (CDS), and severity of Parkinsonism. Subsequent multivariate analysis revealed the number of hospitalizations in the previous 36 months, baseline CDS, severity of Parkinsons, history of substance abuse, and lifetime suicide attempts. Clozapine, in general, was more effective than olanzapine in decreasing the risk of suicidality, regardless of risk factors present. CONCLUSIONS This is the first prospective analysis of predictors of suicide risk in a large schizophrenic and schizoaffective population judged to be at high risk for suicide. Assessment of these risk factors may aid clinicians in evaluating risk for suicidal behaviors so that appropriate interventions can be made.

The InterSePT scale for suicidal thinking reliability and validity

BACKGROUND The InterSePT Scale for Suicidal Thinking (ISST) is a 12-item instrument for the assessment of current suicidal ideation in patients with schizophrenia and schizoaffective disorders. We report the psychometric characteristics of this new scale based on two studies. METHOD In Study 1, 22 inpatients with schizophrenia and schizoaffective disorders, who had recently attempted suicide or engaged in suicidal ideation, were rated by three trained independent raters to examine interrater reliability. In Study 2, a total of 980 patients with schizophrenia or schizoaffective disorder with a history of suicidal ideation in the past 36 months were enrolled in a 2-year industry-sponsored suicide prevention study. At baseline, these patients were administered the ISST and the Clinical Global Impression Scale for Severity of Suicidality (CGI-SS) by the Principal Investigator (PI) and by a blinded rater (BR), who also administered the Positive and Negative Symptom Scale (PANSS), the Calgary Depression Scale (CDS), and the Scale of Functioning (SOF). Indices of internal reliability, construct and discriminant validity were examined. RESULTS The intraclass correlation coefficient (ICC) for the total ISST score for the 22 subjects in Study 1 was 0.90 and mean weighted item kappa coefficients ranged from 0.66 to 0.92. In Study 2, internal reliability (Cronbach alpha) was high, ranging from 0.86 to 0.89 for the individual items, and the overall Cronbach alpha coefficient for all items was 0.88. The ISST (PI) total score was highly correlated with the CGI-SS by the blind rater (r = 0.61, p < 0.0001). ISST total scores significantly differentiated the different levels of CGI-SS (F = 519.2; p < 0.0001). Results of construct and discriminant validity analyses are also presented. CONCLUSION The ISST is a reliable and valid instrument for the assessment of current suicidal thinking in patients with schizophrenia and schizoaffective disorder by both clinicians and researchers.