Continuity of cannabis use and violent offending over the life course.

BACKGROUND: Although the association between cannabis use and violence has been reported in the literature, the precise nature of this relationship, especially the directionality of the association, is unclear. METHOD: Young males from the Cambridge Study of Delinquent Development (n = 411) were followed up between the ages of 8 and 56 years to prospectively investigate the association between cannabis use and violence. A multi-wave (eight assessments, T1-T8) follow-up design was employed that allowed temporal sequencing of the variables of interest and the analysis of violent outcome measures obtained from two sources: (i) criminal records (violent conviction); and (ii) self-reports. A combination of analytic approaches allowing inferences as to the directionality of associations was employed, including multivariate logistic regression analysis, fixed-effects analysis and cross-lagged modelling. RESULTS: Multivariable logistic regression revealed that compared with never-users, continued exposure to cannabis (use at age 18, 32 and 48 years) was associated with a higher risk of subsequent violent behaviour, as indexed by convictions [odds ratio (OR) 7.1, 95% confidence interval (CI) 2.19-23.59] or self-reports (OR 8.9, 95% CI 2.37-46.21). This effect persisted after controlling for other putative risk factors for violence. In predicting violence, fixed-effects analysis and cross-lagged modelling further indicated that this effect could not be explained by other unobserved time-invariant factors. Furthermore, these analyses uncovered a bi-directional relationship between cannabis use and violence. CONCLUSIONS: Together, these results provide strong indication that cannabis use predicts subsequent violent offending, suggesting a possible causal effect, and provide empirical evidence that may have implications for public policy.

Mental and personality disorders and abstinence from alcohol: results from a national household survey.

BACKGROUND: The beneficial outcomes associated with moderate compared with low alcohol intake or abstinence may be due to the inclusion of people as 'low consumers', who have stopped consumption because of poor health. We investigated the association between alcohol abstinence and symptoms of common mental disorder and personality disorder, distinguishing between lifelong abstinence and abstinence following previous consumption. METHOD: Analyses were based on the British National Survey of Psychiatric Morbidity 2000, which sampled 8580 residents aged 16-74 years. Hazardous drinking (Alcohol Use Disorders Identification Test) was excluded. Symptoms of common mental disorder (depression/anxiety) were identified by the Clinical Interview Schedule. The screening questionnaire of the Structured Clinical Interview for Axis II Personality Disorders was used to identify potential personality disorder. Self-reported alcohol abstinence was divided into lifelong abstinence and previous consumption. Previous consumers were asked why they had stopped. Covariates included socio-economic status, social activity and general health status. RESULTS: After adjustment, alcohol abstinence was associated with both common mental disorder symptoms and any personality disorder, but only for previous consumers, in whom odds ratios were 1.69 (95% CI 1.23-2.32) and 1.45 (95% CI 1.09-1.94). Associations were non-specific, being apparent for most individual mental disorder symptoms and personality disorder categories. More detailed analysis indicated that associations were again limited to previous consumers who reported ceasing alcohol consumption for health reasons. CONCLUSIONS: Worse mental health in low alcohol consumers, particularly those who have previously ceased for health reasons, should be taken into account when interpreting associations between moderate (compared with low) alcohol consumption and beneficial health outcomes.

Borderline personality disorder: health service use and social functioning among a national household population.

BACKGROUND: It is unclear whether Axis II psychopathology or co-morbid clinical syndromes result in the treatment-seeking behaviour and social impairment of patients with borderline personality disorder (BPD). This study examined the independent associations between social functioning and service use and Axis I and Axis II disorders in persons with BPD in the national household population of Britain. METHOD: The study was a cross-sectional survey of adults aged 16-74 years in households (n=8397). Data included self-reported consultations with health-care professionals and behavioural problems. Diagnosis was determined by computer-assisted interviews. Analyses included logistic regression adjusting for demography, co-morbid Axis I clinical syndromes and other Axis II disorders. RESULTS: Consultation in the past year was reported by 57.5% of persons with BPD but only 13.4% reported lifetime psychiatric admission. BPD was not independently associated with impaired functioning but was associated with co-morbid psychotic, depressive and anxiety disorders. Only general practitioners (GPs) were consulted for problems independently due to BPD. CONCLUSIONS: Functional effects of BPD are mediated through co-morbid clinical syndromes, not Axis II psychopathology. A subgroup do not have co-morbid disorders or seek treatment, and are high functioning.

Psychoses, ethnicity and socio-economic status.

BACKGROUND: Consistent observation of raised rates of psychoses among Black and minority ethnic (BME) groups may possibly be explained by their lower socio-economic status. AIMS: To test whether risk for psychoses remained elevated in BME populations compared with the White British, after adjustment for age, gender and current socio-economic status. METHOD: Population-based study of first-episode DSM-IV psychotic disorders, in individuals aged 18-64 years, in East London over 2 years. RESULTS: All BME groups had elevated rates of a psychotic disorder after adjustment for age, gender and socio-economic status. For schizophrenia, risk was elevated for people of Black Caribbean (incidence rate ratios (IRR)=3.1, 95% CI 2.1-4.5) and Black African (IRR=2.6, 95% CI 1.8-3.8) origin, and for Pakistani (IRR=3.1, 95% CI 1.2-8.1) and Bangladeshi (IRR=2.3, 95% CI 1.1-4.7) women. Mixed White and Black Caribbean (IRR=7.7, 95% CI 3.2-18.8) and White Other (IRR=2.1, 95% CI 1.2-3.8) groups had elevated rates of affective psychoses (and other non-affective psychoses). CONCLUSIONS: Elevated rates of psychoses in BME groups could not be explained by socio-economic status, even though current socio-economic status may have overestimated the effect of this confounder given potential misclassification as a result of downward social drift in the prodromal phase of psychosis. Our findings extended to all BME groups and psychotic disorders, though heterogeneity remains.

Debt, income and mental disorder in the general population.

BACKGROUND: The association between poor mental health and poverty is well known but its mechanism is not fully understood. This study tests the hypothesis that the association between low income and mental disorder is mediated by debt and its attendant financial hardship. METHOD: The study is a cross-sectional nationally representative survey of private households in England, Scotland and Wales, which assessed 8580 participants aged 16-74 years living in general households. Psychosis, neurosis, alcohol abuse and drug abuse were identified by the Clinical Interview Schedule--Revised, the Schedule for Assessment in Neuropsychiatry (SCAN), the Alcohol Use Disorder Identification Test (AUDIT) and other measures. Detailed questions were asked about income, debt and financial hardship. RESULTS: Those with low income were more likely to have mental disorder [odds ratio (OR) 2.09, 95% confidence interval (CI) 1.68-2.59] but this relationship was attenuated after adjustment for debt (OR 1.58, 95% CI 1.25-1.97) and vanished when other sociodemographic variables were also controlled (OR 1.07, 95% CI 0.77-1.48). Of those with mental disorder, 23% were in debt (compared with 8% of those without disorder), and 10% had had a utility disconnected (compared with 3%). The more debts people had, the more likely they were to have some form of mental disorder, even after adjustment for income and other sociodemographic variables. People with six or more separate debts had a six-fold increase in mental disorder after adjustment for income (OR 6.0, 95% CI 3.5-10.3). CONCLUSIONS: Both low income and debt are associated with mental illness, but the effect of income appears to be mediated largely by debt.

Drug use and initiation in prison: results from a national prison survey in England and Wales.

AIMS: To investigate heroin and cocaine use in a sample of British prisoners, and to explore the characteristics of inmates who use these drugs for the first time while in prison. DESIGN, PARTICIPANTS: A cross-sectional survey of all prisons in England and Wales conducted as part of a major national study of psychiatric morbidity. A total of 3142 prisoners (88.2% of those selected) completed a structured interviewer-administered questionnaire. MEASUREMENTS: Interview measures of personal demographics, social history, psychiatric morbidity and drug use. Personality disorders were diagnosed via the Structured Clinical Interview for DSM-IV (SCID-II) and neurotic symptoms were assessed using the revised Clinical Interview Schedule (CIS-R). FINDINGS: More than 60% of the heroin users and cannabis users reported that they had used these drugs in prison compared with less than a quarter of the life-time cocaine users. More than a quarter of the heroin users reported that they had initiated use of this drug in prison. The extent of an individual's experience of prison was related more consistently to heroin and/or cocaine use in and out of prison than other personal background, social history or psychiatric variables assessed. CONCLUSIONS: The findings indicate that prisons are a high-risk environment for heroin and other drug initiation and use. Although related to drug use, psychiatric variables were not generally associated with initiation in prison, which was dominated by prison exposure. There is a need to explore ways of reducing heroin initiation in prison as part of a broader risk-prevention strategy.

Psychosis and drug dependence: results from a national survey of prisoners.

BACKGROUND: The links between drug use and psychosis are of major aetiological and prognostic significance. Psychosis and drug dependence frequently co-occur within the prison population, providing the opportunity to study this link more closely. AIMS: To explore the relationship between psychosis and drug dependence in a sample of prisoners. METHOD: A total of 3142 prisoners were surveyed nationally, and structured clinical data were obtained from a subsample of 503 respondents. Psychiatric assessment was based on the Schedules for Clinical Assessment in Neuropsychiatry (version 1.0). Measures of amphetamine, cannabis, cocaine and heroin use and dependence were obtained through self-report. RESULTS: Logistic regression analyses indicated that first use of amphetamines or cocaine before the age of 16 years and severe cannabis or cocaine dependence were related to an increased risk of psychosis. In contrast, severe dependence on heroin was associated with a reduced risk of this classification. CONCLUSIONS: Severe dependence on cannabis and psychostimulants is associated with a higher risk of psychosis and is in contrast to severe dependence on heroin, which has a negative relationship with psychosis.

The Federal Administrative Maximum Penitentiary, Florence, Colorado.

Policies for the control of dangerous and disruptive prisoners in European penal institutions depend upon social regimes managed by prison staff. These contrast with certain US regimes where there is increasing use of the incapacitation approach. This paper describes an incapacitation regime developed in the US Federal Administrative Maximum Penitentiary (ADX), Florence, Colorado which is complemented by an architectural design minimizing contact between prisoners and staff. This is reported to have been highly effective in controlling violent and predatory behaviour, escapes, drug-taking, and the influence of members of criminal gangs and notorious prisoners transferred to the ADX. Despite a shift of policy from therapeutic intervention towards deterrence of problem behaviour in prisons in some European countries, such as the UK, it is unlikely that such a regime would be acceptable in Europe.

Relation between childhood sexual and physical abuse and risk of revictimisation in women: a cross-sectional survey.

BACKGROUND: Women who are physically and sexually abused in childhood are at increased risk of victimisation in adulthood. Research has concentrated on sexual revictimisation, and has not included investigation of other abusive experiences, nor examination of prevalence and effects of abuse on adult revictimisation. We aimed to examine the relation between childhood trauma and adult revictimisation, and identify confounding factors. METHODS: We did a cross-sectional survey of 2592 women who were attending primary care practices in east London, UK, with self-administered anonymous questionnaires. We included questions on physical and sexual abuse in childhood; on domestic violence, rape, indecent assault, and other traumatic experiences in adulthood; and on alcohol and other drug abuse. We analysed associations between childhood and adulthood abuse with multiple logistic regression. FINDINGS: 1207 (55%) of 2192 eligible women were recruited and completed the questionnaire. Abusive experiences co-occurred in both childhood and adulthood. Repetition and severity of childhood abuse were independently associated with specific types of adult revictimisation. Unwanted sexual intercourse (<16 years) was associated with domestic violence in adulthood (odds ratio 3.54; 95% CI 1.52-8.25) and with rape (2.84; 1.09-7.35); and severe beatings by parents or carers with domestic violence (3.58; 2.06-6.20), rape (2.70; 1.27-5.74), and other trauma (3.85; 2.23-6.63). INTERPRETATION: Childhood abuse substantially increases risk of revictimisation in adulthood. Women who have experienced multiple childhood abuse are at most risk of adult revictimisation. Identification of women who have undergone childhood abuse is a prerequisite for prevention of further abuse.

Community mental health team management in severe mental illness: a systematic review.

BACKGROUND: Community mental health teams are now generally recommended for the management of severe mental illness but a comparative evaluation of their effectiveness is lacking. AIMS: To assess the benefits of community mental health team management in severe mental illness. METHOD: A systematic review was conducted of community mental health team management compared with other standard approaches. RESULTS: Community mental health team management is associated with fewer deaths by suicide and in suspicious circumstances (odds ratio=0.32, 95% Cl 0.09-1.12), less dissatisfaction with care (odds ratio=0.34, 95% Cl 0.2-0.59) and fewer drop-outs (odds ratio=0.61, 95% Cl 0.45-0.83). Duration of in-patient psychiatric treatment is shorter with community team management and costs of care are less, but there are no gains in clinical symptomatology or social functioning. CONCLUSIONS: Community mental health team management is superior to standard care in promoting greater acceptance of treatment, and may also reduce hospital admission and avoid deaths by suicide. This model of care is effective and deserves encouragement.

Women who experience domestic violence and women survivors of childhood sexual abuse: a survey of health professionals' attitudes and clinical practice.

Health professionals do not wish to routinely screen women for a history of domestic violence or childhood sexual abuse. However, over 80% believe that these are significant health care issues. Routine screening should not be prioritised until evidence of benefit has been established.

Predicting admission rates to secure forensic psychiatry services.

BACKGROUND: The planning and development of secure forensic psychiatry services for mentally disordered offenders in England and Wales has proceeded independently within different regional areas. However, certain mental disorders, offenders, and offending behaviour are all more prevalent in geographical areas characterized by socio-economic deprivation and social disorganization. Failure to consider these factors has led to inadequate service provision in some areas and inequity in funding. A new model is required to predict admissions to these services as an aid to resource allocation. METHOD: Actual admissions (N = 3155) to high and medium secure psychiatric services for seven of 14 (pre-reorganization) Regional Health Authorities, 1988-94. Expected admissions were calculated for each district using 1991 census data adjusted for under-enumeration. Standardized psychiatric admission ratios were calculated and a range of social, health status, and service provision data were used as explanatory variables in a regression analysis to determine variation between districts. RESULTS: Actual psychiatric admissions varied from 160% above to 62% below expected for age, sex, and marital status, according to patients' catchment area of origin, measured according to deciles of the distribution of underprivileged area scores at ward level. The most powerful explanatory variables included a composite measure of social deprivation, ethnicity and availability of low secure beds at regional level. CONCLUSION: Admission rates to secure forensic psychiatry services demonstrate a linear correlation with measures of socio-economic deprivation in patients catchment area of origin. A model was developed to predict admissions from District Health Authorities and is recommended for future use in resource allocation. Identification of factors that explain higher admission rates of serious offenders with mental disorder from deprived areas is a priority for future research.

Medium secure forensic psychiatry services: comparison of seven English health regions.

BACKGROUND: Regional medium secure developments have proceeded unevenly, with wide variations in resources to deliver services. AIMS: To compare patients admitted to seven (pre-reorganisation) regional services and styles of service delivery. METHOD: A record survey of a complete sample of 2608 patients admitted on 3403 occasions between 1 January 1988 and 31 December 1994. RESULTS: Services differed according to location of patients before admission, their legal basis for detention, criminal and antisocial behaviour, diagnosis, security needs and length of stay. Regions with more resources and lower demand provided a wider range of services. Thames services were relatively under-provided during the study period, with North East Thames substantially reliant on admissions to private hospitals. CONCLUSIONS: Uncoordinated development led to under-provision despite high demand. Certain regions prioritised offender patients and did not support local psychiatric services. New standards are required for service specification and resource allocation to redress inequality. Traditional performance measures were of limited usefulness in comparing services.

Ethnic differences in admissions to secure forensic psychiatry services.

BACKGROUND: Persons of African-Caribbean origin are more frequently imprisoned, and increasing evidence suggests they are detained more frequently in psychiatric hospitals, following offending behaviour. AIMS: To estimate population-based prevalence rates of treated mental disorder in different ethnic groups compulsorily admitted to secure forensic psychiatry services. METHOD: A survey was recorded of 3155 first admissions, from 1988 to 1994, from half of England and Wales, with 1991 census data as the denominator adjusted for under-enumeration. RESULTS: Compulsory admissions for Black males were 5.6 (CI 5.1-6.3) times as high as, and for Asian males were half, those for White males; for Black females, 2.9 (CI 2.4-4.6) times as high and for Asian females one-third of those for White females. Admissions of non-Whites rose over the study period. Patterns of offending and diagnoses differed between ethnic groups. CONCLUSIONS: Variations in compulsory hospitalisation cannot be entirely attributed to racial bias. Community-based services may be less effective in preventing escalating criminal and dangerous behaviour associated with mental illness in African-Caribbeans.

Community mental health teams (CMHTs) for people with severe mental illnesses and disordered personality.

BACKGROUND: Closure of asylums and institutions for the mentally ill, coupled with government policies focusing on reducing the number of hospital beds for people with severe mental illness in favour of providing care in a variety of non-hospital settings underpins the rationale behind care in the community. A major thrust towards community care has been the development of community mental health teams (CMHT). OBJECTIVES: To evaluate the effects of community mental health team (CMHT) treatment for anyone with serious mental illness. SEARCH STRATEGY: Electronic searches of Biological Abstracts (1982-1997), the Cochrane Library (1998, Issue 2), EMBASE (1980-1997), MEDLINE (1966-1997), PsycLIT (1974-1997) and SCISEARCH (1997) were undertaken. The Journal of Personality Disorders was hand searched, and contact was made with colleagues at ENMESH, ISSPD and in forensic psychiatry. SELECTION CRITERIA: All randomised or quasi-randomised controlled trials of CMHT management versus non-team standard care. DATA COLLECTION AND ANALYSIS: The selection of trials, assessment of quality and data extraction was undertaken independently and in parallel by two reviewers. Where possible the data were entered into RevMan and an intention-to-treat analysis undertaken. Tests of heterogeneity were undertaken. MAIN RESULTS: CMHT management may be associated with fewer deaths by suicide and in suspicious circumstances (OR 0.32 CI 0.09-1.12). It causes less people to be dissatisfied with their care (OR 0.34 CI 0.2-0.59) and to leave the studies early (OR 0.61 CI 0.45-0.83). No clear difference was found in admission rates, overall clinical outcomes and duration of in-patient hospital treatment, although this was partly a consequence of poorly presented data. REVIEWER'S CONCLUSIONS: Community mental health team management is not inferior to non-team standard care in any important respects and is superior in promoting greater acceptance of treatment. It may also be superior in reducing hospital admission and avoiding death by suicide.

Empirical clusters of DSM-III personality disorders in violent offenders.

Violent male offenders in a maximum security hospital and special units in prisons (N = 164) were interviewed with the Structured Clinical Interview for DSM-III Axis II disorders (SCID-II). Cluster analysis of the personality disorder criteria sets identified six diagnostic patterns: (1) antisocial-narcissistic; (2) paranoid-antisocial; (3) borderline-antisocial-passive-aggressive; (4) borderline; (5) compulsive-borderline; and (6) schizoid. Offenders in the first three groups had more extensive criminal careers, and most were identified as psychopaths by the Psychopathy Checklist-Revised (PCL-R). These Groups also had more frequent lifetime histories of substance abuse. A history of affective and anxiety disorders was more common in Groups 3 and 5, and almost two thirds of Group 2 had a history of psychotic disorder. The results emphasize that dangerous offenders are heterogeneous in personality pathology. They also suggest that personality disorder among violent offenders is more commonly represented by recurring patterns of covarying traits than by single categorical entities proposed in the DSM classification.

Patients with personality disorder admitted to secure forensic psychiatry services.

BACKGROUND: Treatment of patients with personality disorder remains controversial and severe mental illness is prioritized in secure forensic psychiatry services. AIMS: To compare patients with personality disorder and mental illness according to demography, referral, criminality, previous institutionalisation and diagnostic comorbidity. METHOD: A record survey of 511 patients with personality disorder and 2575 with mental illness admitted to secure forensic psychiatry services between 1 January 1988 and 31 December 1994 from half of England and Wales. RESULTS: Personality disorder admissions declined over time; more were female, White, younger and extensively criminal (specifically, sexual and arson offences). Personality disorder was highly comorbid; antisocial, borderline, paranoid and dependent personality disorder were most prevalent. CONCLUSIONS: Patients with personality disorder were highly selected and previously known to psychiatric services. Referrer, diagnostic comorbidity and behavioural presentation determined their pathways into care. Future research must determine whether their continuing admission represents effective use of scarce resources and whether new services are required.

Aetiological risk factors for personality disorders.

BACKGROUND: Elucidation of aetiological processes leading to development of Axis II disorders is important in category validation and could lead to new treatments. AIMS: To establish aetiological associations between Axis II disorders and specific risk factors. METHOD: Male and female subjects (n = 260) in maximum security hospitals and prisons were interviewed to determine DSM-III Axis II and lifetime Axis I diagnoses. Aetiological risk factors were obtained at interview and from case files. Independent statistical associations were established by logistic regression. RESULTS: Axis II categories were divided into four groups: (a) disorders of character development, secondary to an adverse early environment: antisocial, self-defeating and paranoid; (b) disorders of temperament, secondary to constitutional aetiology: avoidant, dependent, schizoid and schizotypal; (c) a 'mixed' disorder of constitutional and environmental aetiology: borderline; and (d) aetiological associations not established: narcissistic, histrionic, compulsive and passive-aggressive. CONCLUSIONS: The study validates several Axis II categories but challenges the inclusion of others within Axis II of DSM-IV, in particular schizoid, schizotypal, avoidant and borderline personality disorders. The findings have implications for future treatment interventions.