Social disadvantage, mental illness and predictors of legal involvement.

The following study evaluates the complex association between legal involvement and mental illness. It describes a population of consumers of community mental health programs, comparing those with legal involvement to those without legal involvement, on a number of demographic, clinical and social indicators. It is a secondary analysis of data collected in studies making up the Community Mental Health Evaluation Initiative (CMHEI) in the province of Ontario, Canada. Legal involvement was a significant issue among community mental health program consumers; about one in five consumers had at least some contact with the legal system in the preceding nine months. Legally involved consumers were more likely to be in receipt of social assistance and be unstably housed than those legally uninvolved. However, there were no significant differences between legally involved and uninvolved consumers with respect to severity of symptomatology, current medication use or number of hospitalization days in the past 9 months. A predictive model compared the differential impact of clinical and social determinants upon legal involvement. Analyses failed to uncover a significant relationship between severity of psychiatric symptomatology and legal involvement. Significant predictors of legal involvement included gender, race, drug use as well as housing instability, and receipt of social assistance. Legal involvement was attributable to factors other than the severity of mental illness; these results challenge assumptions that the most symptomatically severe consumers are most at risk of legal involvement. Accordingly, the rate of legal involvement in a sample of community mental health program users must be considered in a broad context, with particular emphasis on social disadvantage.

Epidemic theory and group violence.

BACKGROUND: Epidemics can be represented mathematically using a variety of models. One of these, the Kermack-McKendrick model, has been used to support health policy decisions concerning vaccination requirements. An unrelated body of literature suggests that some behaviours, including some types of violence, may spread in ways analogous to the contagious spread of infectious diseases, a process that has been characterized as "behavioural contagion". METHOD: Various parameter values reflecting the characteristics of crowds were substituted into the Kermack-McKendrick model. Computer simulations were used to evaluate the impact of these parameter values. RESULTS: The simulations reproduced several features of crowd violence: the tendency for riots to occur in large groups, the importance of rapid removal of violent individuals from crowds, and the roles of alcohol consumption and social identification processes. CONCLUSIONS: Epidemic models may be of relevance to the prevention and control of violent behaviour as they can assist with the identification of high-risk situations and prevention strategies. Theoretical constructs related to epidemic theory may have broad applicability for modelling the unstable course of some mental disorders.

A public health perspective on violent offenses among persons with mental illness.

OBJECTIVE: This study reanalyzed existing data to assess the extent to which persons with mental illness might contribute to criminal violence in the community. METHODS: Data were examined from a representative sample of 1,151 remanded offenders who underwent a full structured diagnostic interview that was used to provide one-month prevalence rates of mental illnesses as defined by the Structured Clincal Interview for DSM-III-R. Diagnoses of interest were mood, psychotic, anxiety, psychoactive substance use, adjustment, and miscellaneous axis I disorders and axis II personality disorders. Criminological data describing the number of offenses against persons and property and the number of victimless crimes were abstracted from police arrest reports and warrants. A violent crime was defined as any crime against a person. RESULTS: The one-month prevalence of major mental and substance use disorders of newly admitted inmates was 61 percent. About 3 percent of violent offenses could be attributed to individuals who had a principal diagnosis of any non-substance use-related disorder. An additional 7 percent of violent offenses could be attributed to individuals who had a primary diagnosis of a substance use disorder. CONCLUSIONS: The results of the study support the hypothesis that people with mental and substance use disorders are not major contributors to police-identified criminal violence. Public perceptions of mentally ill persons as criminally dangerous appear to be greatly exaggerated.

Community attitudes toward people with schizophrenia.

OBJECTIVE: We surveyed public attitudes toward people with schizophrenia as part of a pilot project for the World Psychiatric Association's Global Campaign to Fight Stigma and Discrimination Because of Schizophrenia. METHODS: We conducted random-digit telephone surveys with 1653 respondents (aged 15 years or over) residing in 2 adjacent rural and urban health regions (71.9% response rate). A brief interview collected information on experiences with people with a mental illness or schizophrenia, knowledge of causes and treatments for schizophrenia, and levels of social distance felt toward people with schizophrenia. RESULTS: One-half of the sample had known someone treated for schizophrenia or another mental illness. Of those able to identify a cause of schizophrenia (two-thirds), most identified a biological cause, usually a brain disease. Social distance increased with the level of intimacy required. One in 5 respondents thought they would be unable to maintain a friendship with, one-half would be unable to room with, and three-quarters would be unable to marry, someone with schizophrenia. Those over 60 were least knowledgeable or enlightened and the most socially distancing. Greater knowledge was associated with less-distancing attitudes. When other factors were controlled, exposure to the mentally ill was not correlated with knowledge or attitudes, even among those who had worked in agencies providing services to the mentally ill. CONCLUSIONS: Most respondents were relatively well informed and progressive in their reported understanding of schizophrenia and its treatment. Clear subgroup differences were apparent with respect to age and knowledge. Knowledge of schizophrenia, not exposure to the mentally ill, was a central modifiable correlate of stigma.

Homeless shelter users in the postdeinstitutionalization era.

OBJECTIVE: To describe the psychiatric symptomatology and mental health service needs of homeless shelter users in Calgary, Alberta. Data were collected as part of a broad-based community action initiative designed to reduce the problem of homelessness. METHODS: A semistructured interview was conducted with a representative sample of 250 emergency shelter users. Mental health problems were measured through self-reports of 9 psychiatric symptoms known to be related to illnesses prevalent among homeless populations (depression, anxiety, and psychoses). The CAGE alcohol screen was also used. RESULTS: Three-quarters of the sample expressed some symptomatology. About one-third were estimated to have a significant mental health problem. The lifetime prevalence of alcohol abuse was 33.6%. Higher levels of psychiatric symptomatology appeared to relate to a wide range of hardships, personal and public health risks, addictive behaviours, victimization, economic and interpersonal life events, dissatisfaction, and stress. Also, those with significant symptomatology frequently needed mental health care services but often did not know where to access them. CONCLUSIONS: The prevalence of mental health and substance abuse problems within homeless populations is significant and associated with considerable hardship as well as personal and public health risks.

The Canadian Criminal Code provisions for mentally disordered offenders: a survey of experiences, attitudes, and knowledge.

OBJECTIVE: To systematically survey Alberta psychiatrists and lawyers regarding their knowledge of, attitudes toward, and experiences with the Criminal Code provisions regarding mentally disordered offenders to better understand the lack of impact in practice patterns. METHOD: A survey design was used, and 2 questionnaires, 1 for lawyers and 1 for psychiatrists, were developed and mailed out. RESULTS: Out of 245 surveys sent to psychiatrists, 141 were returned, giving a response rate of 57%. The number of lawyers practising criminal law could not be determined, and 5273 surveys were sent to all lawyers on the Law Society of Alberta mailing list. Of these, 564 were returned, giving an overall response rate of 11%. The response rate for lawyers practising criminal law is unknown. Overall, lawyers were younger than psychiatrists. Most of the respondents in both groups were men. Overall, attitudes toward offenders with mental illness were very similar among lawyers and psychiatrists. Compared with lawyers, psychiatrists had significantly more correct responses to the items assessing knowledge. With a highest possible knowledge score of 27, the average score was 16 (SD 5.7) for psychiatrists and 13 (SD 7.23) for lawyers. CONCLUSIONS: The lack of familiarity with many of the key provisions among psychiatrists and lawyers is worrisome and suggests the need for educational materials to improve knowledge of the Criminal Code provisions governing mentally disordered offenders.

Elderly suicide in Alberta: difference by gender.

OBJECTIVE: To determine differences by gender among elderly persons who commit suicide on demographic characteristics, place of suicide, suicide method, previous suicide behaviour, and precipitant stressor. METHOD: This study included completed suicides of individuals aged 55 years and over during 1984-1995 in Alberta (n = 920). Information was abstracted from suicide records of medical examiners. RESULTS: Relative to elderly female suicides, elderly males who commit suicide characteristically use guns to commit suicide (43.8%), are single (12.5%), live in rural areas (46.7%), and have a lower frequency of previous suicide attempts (16.5%). Physical illness and financial difficulty as precipitant stressors of suicide are significantly more frequent among males (40.3% and 8.7% respectively) than females (29.9% and 1.8% respectively). Mental illness as a precipitant stressor is more common among females, 35.8% for women and 15.3% for men. CONCLUSIONS: Lethal methods of suicide and physical illness and financial difficulty as precipitant stressors of suicide are more common among elderly males than females who commit suicide.

Understanding causal paths between mental illness and violence.

The stigma associated with mental illness is a major concern for patients, families, and providers of health services. One reason for the stigmatization of the mentally ill is the public perception that they are violent and dangerous. Although, traditionally, mental health advocates have argued against this public belief, a recent body of research evidence suggests that patients who suffer from serious mental conditions are more prone to violent behaviour than persons who are not mentally ill. It is a point of contention, however, whether the relationship between mental illness and violence is only one of association, or one of causality; that mental illness causes violence. A proven causal association between mental illness and violence will have major consequences for the mentally ill and major implications for caregivers, communities, and legislators. This paper outlines the key methodological barriers precluding casual inferences at this time. The authors suggest that a casual inference about mental illness and violence may yet be hasty. Because a premature statement advocating a causal relationship between mental illness and violence could increase stigma and have devastating effects on the mentally ill the authors urge researchers to consider the damage that may be produced as a result of poorly substantiated causal inferences.

Mental illness and violence: an epidemiological appraisal of the evidence.

OBJECTIVE: To conduct a critical review of the literature on the matter of mental illness and violence, to examine whether there is enough evidence to establish a causal link, and to provide epidemiological background to measure the risk to the population. METHOD: Based on a computerized search of the literature on mental illness and violence previously conducted for Health Canada, studies in the area were critically reviewed and divided into 3 main categories: 1) studies of criminal and violent behaviour among psychiatric patients, 2) studies of psychiatric illness among offenders (prevalence studies in institutions, analytical studies, and community follow-up of offenders), and 3) epidemiological community-based studies on the issue of mental illness and violence (police-citizen encounters, representative samples, and other epidemiological studies). Causality rules and measures of risk were then applied to the evidence elicited. RESULTS: The review of the literature suggests that only a small minority of hospitalized patients, typically those suffering from acute psychotic symptoms, are involved in violent incidents. Formerly hospitalized patients are at a higher risk of committing violence if they are not properly treated and are experiencing threat/control-override psychotic symptoms. Substance abuse disorders significantly raise the risk for violence. Family members are the most at risk of being victimized. CONCLUSION: An association exists between mental illness and violence, but the many covariations that naturally affect the equation between them introduce uncertainties in establishing causality.

The incidence of delirium in psychiatric inpatient units.

OBJECTIVES: To estimate prospectively the incidence of delirium in psychiatric inpatients and to identify risk factors for delirium in this population. METHOD: The subjects were nondelirious patients newly admitted to the Calgary General Hospital. The Delirium Symptom Interview (DSI), the Confusion Assessment Method (CAM), and the Mini-Mental State Examination (MMSE) were used to identify incident cases of delirium. In order to evaluate the potential impact of selection bias, we conducted a supplementary analysis using record linkage to an electronic administrative data base with coverage of the target population. RESULTS: Of 420 admissions to the hospital, 401 subjects provided informed consent and were not delirious at the time of admission. There were 9 incident cases of delirium. The cumulative incidence rate was, therefore, 2.14 per 100 admissions. The record linkage analysis did not uncover evidence of selection bias. Delirium was associated with a significantly increased length of stay in hospital. CONCLUSIONS: Delirium is an uncommon incident event in the psychiatric inpatient population. The incidence rate reported here may be useful as a benchmark for the identification of excessive rates in other inpatient settings. Since delirium is sometimes related to modifiable therapeutic factors, an excessive rate should prompt a search for its causes.

Ethical research with the mentally disordered.

Because of concerns about competence and voluntariness, the mentally disordered constitute a vulnerable population in the context of nontherapeutic biomedical research and, as such, are in need of protection. Despite others' concern about protecting the mentally disordered, their decision-making potential should also be respected and maximized, allowing such individuals to consent to participate in experiments subject to an evaluation of their competence to make such a decision. Competent mentally disordered persons who anticipate future incapacity should be able to issue research directives or durable powers of attorney whereby they can provide explicit consent to participate in nontherapeutic research. When he or she becomes incompetent, a substitute decision maker should be able to provide consent on behalf of the mentally disordered person within established parameters. Nontherapeutic experimentation with the mentally disordered should be permitted, but only within the boundaries of ethical permissibility delineated by legislated guidelines. At present, the legal status of substituted consent for nontherapeutic procedures is uncertain and requires legislation, which in addition to legalizing such consent, would provide guidelines for substitute decision makers and for the creation of research directives. These guidelines should include restrictions on the scope of research, obligations of researchers, rights of subjects, and responsibilities of research ethics committees (RECs). In all cases, the voluntary and informed consent of the person or substitute decision maker must be obtained.

Ethical research with the developmentally disabled.

The developmentally disabled constitute a vulnerable population in the context of nontherapeutic experimentation. Their vulnerability is characterized by diminished decision-making capacity and by susceptibility to coercive situations that may bring voluntariness into question. The international consensus is that research involving this population should be permitted, but only if the consent of a legal guardian is obtained and appropriate safeguards are introduced. Therefore, legislation regulating the ethical conduct of research should be enacted, including provision for substituted consent in the research context. Although researchers seeking the participation of a developmentally disabled individual in a protocol must presume the person to be capable of participating in the decision, they must conduct competency assessments if the person's ability to make such a decision is in doubt. Information must be presented in such a way as to maximize the individual's contribution, and capacity must be reevaluated on an ongoing basis. In addition, research on the developmentally disabled presents specific challenges to establish competency, the selection of subjects, the characteristics of the decision maker, and the model to be used in making substituted decisions.