Multiple adverse outcomes over 30 years following adolescent substance misuse treatment.

OBJECTIVE: To compare outcomes over 30 years experienced by individuals who as adolescents entered substance misuse treatment and a general population sample. METHOD: All 1992 individuals seen at the only clinic for substance misusing adolescents in Stockholm from 1968 to 1971 were compared to 1992 individuals randomly selected from the Swedish population, matched for sex, age and birthplace. Death, hospitalization for physical illness related to substance misuse, hospitalization for mental illness, substance misuse, criminal convictions and poverty were documented from national registers. RESULTS: Relative risks of death, physical illness, mental illness, substance misuse, criminal convictions and poverty were significantly elevated in the clinic compared to the general population sample. After adjustment for substance misuse in adulthood, the risks of death, physical and mental illness, criminality and poverty remained elevated. CONCLUSION: Adolescents who consult for substance misuse problems are at high risk for multiple adverse outcomes over the subsequent 30 years.

Consulting for substance abuse: mental disorders among adolescents and their parents.

Studies conducted outside of Scandinavia indicate that most adolescents with substance misuse problems suffer from co-morbid mental disorders. The present study assessed the mental health of adolescents seeking help for substance misuse problems in a large Swedish city. Parents' mental health was also examined. The sample included 97 girls with their 90 mothers and 52 fathers, and 81 boys with their 72 mothers and 37 fathers. The adolescents completed a diagnostic interview, either the Kiddie-SADs or the Structured Clinical Interview for DSM-IV (SCID) depending on their age. Their parents underwent diagnostic interviews with the SCID. Ninety per cent of the girls and 81% of the boys met criteria for at least one disorder other than substance misuse, and on average, they suffered from three other disorders, most of which had onset before substance misuse began. Almost 80% of the mothers and 67% of the fathers met criteria for at least one mental disorder other than alcohol and drug-related disorders. The findings concur with those reported from studies conducted in North America. The results suggest that in Sweden mental disorders are not being identified and effectively treated among some children and young adolescents who subsequently abuse alcohol and/or illicit drugs. Adolescents who consult for substance abuse problems require assessments and treatment by mental health professionals.

Patient expectation and satisfaction in revision total hip arthroplasty.

Sixty-six consecutive revision total hip arthroplasty patients were asked about their expectations regarding future pain and walking ability. Expectations were high, regardless of background factors: 92% expected to have much less pain, and 82% expected the same walking ability as after the primary arthroplasty or a much improved walking ability. Of the patients, 56% stated a non-surgeon-related origin of expectations, 7% were uncertain, and 37% said expectations derived from the surgeon. At 1 year, Harris hip score had increased from a median 45 to 77 points, but only 69% and 55% said that their expectations had been fulfilled to a very large or rather large extent regarding pain and walking ability. The only predictor of fulfilled expectations was absence of complications (odds ratio, 4.8; 95% confidence interval, 1.1-20.8). Patient satisfaction was only moderate; 63% were very or rather satisfied with a moderate correlation (0.46-0.47) between satisfaction and fulfilled expectations. Patients with a poor preoperative hip condition generally were more satisfied (odds ratio, 5.0; 95% confidence interval, 1.4-17.9), and the most important reason probably was an improved walking ability (r = 0.64). Patient dissatisfaction may originate from unrealistic expectations. At preoperative consultation, it is recommended that the surgeon discuss the revision patient's expectations, especially regarding future walking ability, and inform the patient about the fundamental prognostic differences between revision and primary hip arthroplasty.

Criminal behavior of forensic and general psychiatric patients with schizophrenia: are they different?

OBJECTIVE: This study was designed to compare the rate of past criminal behavior among male patients being discharged from forensic and general psychiatric hospitals in four countries. METHOD: Discharged consecutive patients from eight sites, four general and four forensic psychiatric, were included and asked for participation. Transcripts of past criminal behavior were available for this study. Analyses were limited to men with schizophrenia. RESULTS: One in five of the general psychiatric patients had a criminal record. The criminal histories of the offenders in the general and forensic hospitals were similar, except that all patients who had killed were treated in forensic hospitals. CONCLUSION: The results point to the need to assess the risk of violent behavior among general psychiatric patients in order to provide them with appropriate treatments designed to prevent criminal recidivism.

Men with schizophrenia who behave violently: the usefulness of an early- versus late-start offender typology.

Persons who develop schizophrenia are more likely than nondisordered persons to commit crimes. It is important to investigate those who offend, in order to develop treatment programs that effectively prevent recidivism, and eventually, early childhood violence prevention programs. Recent studies have shown that among offenders with major mental disorders, there are two groups: early starters, who begin their criminal careers in adolescence; and late starters, who first offend as adults. The present study examined 272 violent male offenders with schizophrenia in Sweden who underwent a pretrial psychiatric assessment between 1988 and 1995. Early- and late-start offenders were found to present differences in behavior, comorbid disorders, personality traits, and referrals for treatment in childhood, adolescence, and adulthood. Their parents also differed. The findings have implications for treatment and management of offenders with schizophrenia, for risk assessment, and for prevention.

Long-term predictive validity of historical factors in two risk assessment instruments in a group of violent offenders with schizophrenia.

The long-term predictive validity of the Violent Risk Appraisal Guide (VRAG) and the historical part (H-10) of the risk assessment device HCR-20 in predicting violent recidivism was investigated in a sample of (n=106) violent offenders with schizophrenia. An effort was made to validate the 9-bin categorization of different absolute risk to recidivate depending on the individual score on the VRAG. Scores on both devices were retrospectively obtained from various files and registers. Individuals were followed up after discharge from hospital for on average 86 (standard deviation=19.33) months. During follow-up 29% of the sample was reconvicted of a violent crime. Results indicated that both H-10 and VRAG had a moderate ability to predict violent recidivism and that H-10 had a slightly better accuracy. Most of the items in H-10 but only half of those in VRAG correlated significantly with violent recidivism. The 9-bin categorization of VRAG scores produced mixed results. In the Swedish sample there was a linear trend in which increased VRAG scores were associated with higher absolute risk to recidivate. However, the distribution of scores and the figures of absolute risk of recidivation were not replicated. It is concluded that historical factors seem to play an important role for the long-term prediction of future violence among a group of severely mentally ill individuals.

Psychopathy (PCL-R) as a predictor of violent recidivism among criminal offenders with schizophrenia.

Hare's Psychopathy Checklist--Revised (PCL-R) was used to test the hypothesis that psychopathy predicts violent recidivism in a cohort subjected to forensic psychiatric investigation and consisting of male violent offenders with schizophrenia (N = 202). Psychopathy was assessed with retrospective file-based ratings. Mean follow-up time after detainment was 51 months. Twenty-two percent of the offenders had a PCL-R score > or = 26 (cutoff), and the base rate for violent recidivism (reconvictions) during follow-up was 21%. Survival analysis revealed that psychopathy was strongly associated to violent recidivism (log-rank = 17.71, df = 1, p < 0.0001). The area under the curve (AUC) of the receiver operating characteristics (ROC) of PCL-R total score to predict violent recidivism varied between different time frames from .64 to .75. Cox regression analyses revealed that other potential risk factors could not equally well or better explain violent recidivism in the cohort than psychopathy as measured by PCL-R.

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

Psychopathy as conceptualized with Hare's 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.

Suicide among personality-disordered offenders: a follow-up study of 1943 male criminal offenders.

Suicide mortality among all male criminal offenders in Sweden who had been subjected to a major forensic psychiatric examination 1988-1991 (n = 1943) was studied, with special reference to offenders with personality disorders. The cohort was followed until the end of 1995. Altogether 135 individuals (6.9%) died during the follow-up period; the mode of death was suicide in 50 individuals (2.6%). The unadjusted suicide mortality ranged from 2.8% among those with personality disorders to 6.1% among those with drug-related psychosis. The standardised mortality ratio (SMR) among personality-disordered offenders was 1212, i.e. around 12 times that of the general population. Survival analyses by means of Cox regression models were performed to identify background factors associated with completed suicide. No specific principal diagnosis showed significantly increased risk for completed suicide. However, concomitant depression and drug abuse were significantly linked to suicide. Violent crime showed no association. Among personality-disordered offenders suicide methods did not differ from those of suicide victims in the general population. There was no association between violent index criminality or between life-time violent criminality and choice of a violent suicide method.

Reliability of file-based retrospective ratings of psychopathy with the PCL-R.

A rapidly emerging consensus recognizes Hare's Psychopathy Checklist-Revised (PCL-R; Hare, 1991) as the most valid and useful instrument to assess psychopathy (Fulero, 1995; Stone, 1995). We compared independent clinical PCL-R ratings of 40 forensic adult male criminal offenders to retrospective file-only ratings. File-based PCL-R ratings, in comparison to the clinical ratings, yielded categorical psychopathy diagnoses with a sensitivity of .57 and a specificity of .96. The intraclass correlation (ICC) of the total scores as estimated by ICC(2,1) was .88, and was markedly better on Factor 2, ICC(2,1) = .89, than on Factor 1, ICC(2,1) = .69. The findings support the belief that for research purposes, file-only PCL-R ratings based on Swedish forensic psychiatric investigation records can be made with good alternate-form reliability.