A comparison of patient ratings and staff ratings of disability using the World Health Organisation Disability Assessment Schedule in individuals with psychotic spectrum disorders who are forensic psychiatric inpatients.

BACKGROUND: Psychosocial rehabilitation in forensic psychiatric services requires sound measurement of patient and staff perceptions of psychosocial function. The recommended World Health Organisation Disability Assessment Schedule 2.0 (WHODAS), designed for this, has not been examined with offender patients. AIMS: To examine patient and staff WHODAS ratings of secure hospital inpatients with psychosis, any differences between them and explore associations with other clinical factors. METHODS: Seventy-three patients self-rated on the WHODAS after 3 months as inpatients. An occupational therapist interviewed the patient's primary nurse and care team at about the same time (staff ratings). Scores were calculated according to the WHODAS manual. WHODAS scores and interview-rated symptom severity, cognitive measures, daily antipsychotic dose and duration of care were compared. RESULTS: Patient ratings indicated less disability than staff ratings for total score and for the domains of understanding and communicating, getting along and life activities. Self-care and participation ratings were similar. Patients were more likely to rate themselves as disabled in getting around (mobility). Only one-fifth of patient- and staff- ratings (16, 22%) were similar, while for nearly a third of the patients (23, 32%) self-ratings were higher than staff ratings. More severe positive symptoms were associated with higher self-rated WHODAS disability after accounting for treatment duration, negative symptoms, cognitive score and antipsychotic dose. No variable accounted for the staff/patient differences in ratings. CONCLUSION: Our mean WHODAS score findings echoed those in other patient samples-of patient underestimation of disability, linked to severity of symptoms. In this study using the WHODAS for the first time in a forensic mental health secure inpatient service, however, we found that, by comparing individuals, half of the patients reported equivalent or greater disability than did staff. Future research should focus on elucidating from patients what contributes to their self-ratings. Understanding their thought processes in rating may enhance rehabilitation planning.

Cognition, prior aggression, and psychopathic traits in relation to impaired multimodal emotion recognition in psychotic spectrum disorders.

Background: Psychopathic traits have been associated with impaired emotion recognition in criminal, clinical and community samples. A recent study however, suggested that cognitive impairment reduced the relationship between psychopathy and emotion recognition. We therefore investigated if reasoning ability and psychomotor speed were impacting emotion recognition in individuals with psychotic spectrum disorders (PSD) with and without a history of aggression, as well as in healthy individuals, more than self-rated psychopathy ratings on the Triarchic Psychopathy Measure (TriPM). Methods: Eighty individuals with PSD (schizophrenia, schizoaffective disorder, delusional disorder, other psychoses, psychotic bipolar disorder) and documented history of aggression (PSD+Agg) were compared with 54 individuals with PSD without prior aggression (PSD-Agg) and with 86 healthy individuals on the Emotion Recognition Assessment in Multiple Modalities (ERAM test). Individuals were psychiatrically stable and in remission from possible substance use disorders. Scaled scores on matrix reasoning, averages of dominant hand psychomotor speed and self-rated TriPM scores were obtained. Results: Associations existed between low reasoning ability, low psychomotor speed, patient status and prior aggression with total accuracy on the ERAM test. PSD groups performed worse than the healthy group. Whole group correlations between total and subscale scores of TriPM to ERAM were found, but no associations with TriPM scores within each group or in general linear models when accounting for reasoning ability, psychomotor speed, understanding of emotion words and prior aggression. Conclusion: Self-rated psychopathy was not independently linked to emotion recognition in PSD groups when considering prior aggression, patient status, reasoning ability, psychomotor speed and emotion word understanding.

Criminal responsibility evaluations: Benchmarking in different countries.

Forensic mental health experts play a crucial role in criminal responsibility evaluations. However, the quality of these assessments has at time come under scrutiny and has been heavily criticized. A literature review revealed significant differences between countries concerning legal frameworks and procedures for conducting these assessments. The findings suggest that although some countries can be seen as a "role model", there still is room for improvement.

Oxazepam and cognitive reappraisal: A randomised experiment.

BACKGROUND: Cognitive reappraisal is a strategy for emotional regulation, important in the context of anxiety disorders. It is not known whether anxiolytic effects of benzodiazepines affect cognitive reappraisal. AIMS: We aimed to investigate the effect of 25 mg oxazepam on cognitive reappraisal. METHODS: In a preliminary investigation, 33 healthy male volunteers were randomised to oxazepam or placebo, and then underwent an experiment where they were asked to use cognitive reappraisal to upregulate or downregulate their emotional response to images with negative or neutral emotional valence. We recorded unpleasantness ratings, skin conductance, superciliary corrugator muscle activity, and heart rate. Participants completed rating scales measuring empathy (Interpersonal Reactivity Index, IRI), anxiety (State-Trait Anxiety Inventory, STAI), alexithymia (Toronto Alexithymia Scale-20, TAS-20), and psychopathy (Psychopathy Personality Inventory-Revised, PPI-R). RESULTS: Upregulation to negative-valence images in the cognitive reappraisal task caused increased unpleasantness ratings, corrugator activity, and heart rate compared to downregulation. Upregulation to both negative- and neutral-valence images caused increased skin conductance responses. Oxazepam caused lower unpleasantness ratings to negative-valence stimuli, but did not interact with reappraisal instruction on any outcome. Self-rated trait empathy was associated with stronger responses to negative-valence stimuli, whereas self-rated psychopathic traits were associated with weaker responses to negative-valence stimuli. CONCLUSIONS: While 25 mg oxazepam caused lower unpleasantness ratings in response to negative-valence images, we did not observe an effect of 25 mg oxazepam on cognitive reappraisal.

Psychotically driven aggression is associated with greater mentalizing challenges in psychotic spectrum disorders.

BACKGROUND: Some aggressive acts committed by individuals with psychotic spectrum disorders (PSD) are understandable in the context of interpersonal conflict or goal attainment, yet others are unpredictable, arising from delusions or hallucinations (psychotically driven aggressive acts, PDA). It is unknown if there are underlying differences in cognitive or perceptive social cognition in relation to aggression motivation in PSD. METHOD: We compared differences in social cognition performance between 49 individuals with PSD who had committed PDA with those exhibiting other types of aggression (n = 31) (non-PDA) and to community controls (n = 81) on the Swedish version of Double Movie for the Assessment of Social Cognition - Multiple Choice (DMASC-MC). Participants with PSD had more than 3 months of clinical stability and substance use abstention and stable antipsychotic medication doses. General intellectual ability was assessed with the information and matrix reasoning subtests of the Wechsler Intelligence Scales. RESULTS: The PSD group with a history of PDA exhibited lower total and perceptive social cognition scores on the DMASC-MC than the non-PDA group and controls. In addition, they also showed lower cognitive scores compared to typical controls. Lower total scores were associated with lower scores on Wechsler intelligence subtests information and matrix reasoning. Taking this into account, the PDA group still had lower social cognition scores. There were no associations of antipsychotic medication dosages, positive or negative symptoms with social cognition scores. Higher antipsychotic dosage at the time of DMASC-MC testing and social cognition scores predicted a past history of PDA. CONCLUSIONS: We conclude that impaired social cognition, particularly perceptive social cognition, is associated with PDA in individuals with PSD.

Infection during childhood and the risk of violent criminal behavior in adulthood.

Infections during brain development appear to contribute to cognitive impairment and aggressive behavior, as well as to a number of developmental mental disorders closely associated with violent criminal behavior. Yet, no study has thus far ever investigated whether infections during brain development increases the risk of violent criminality later in life. In this population-based cohort study, about 2.2 million individuals born in Sweden between the years 1973 and 1995 were included in an effort to estimate the association between infections during childhood (registered ICD-10 diagnoses of infections incurred before the age of 14 years) and violent criminal behavior (registered convictions for a violent crime between the ages of 15 and 38 years, prior to December 31, 2011). After inclusion of several sociodemographic parameters, risks of violent criminal behavior conferred by childhood infections - expressed as hazard ratios (HRs) and 95% confidence intervals (CIs) - were calculated by means of Cox regression. Mediation analyses were performed to explore the effect of psychiatric disorders on the association between infections during childhood and violent criminality. Results revealed a modest, yet significant, association between an infection during childhood and violent criminality later in life (adjusted HR 1.14, 95% CI 1.12-1.16). Infections during the first year of life and infections in the central nervous system were associated with the highest risks of subsequent violent criminality (adjusted HR 1.20, 95% CI 1.18-1.23, and adjusted HR 1.17, 95% CI 1.08-1.26, respectively). The association was partly mediated by the presence of a psychiatric disorder. In summary, independent of a wide range of covariates, our results suggest that infections during brain development could be part of the genesis of violent criminal behavior.

Impaired facial emotion perception of briefly presented double masked stimuli in violent offenders with schizophrenia spectrum disorders.

Social interactions require decoding of subtle rapidly changing emotional cues in others to facilitate socially appropriate behaviour. It is possible that impairments in the ability to detect and decode these signals may increase the risk for aggression. Therefore, we examined violent offenders with schizophrenia spectrum disorders (SSD) and compared these with healthy controls on a computerized paradigm of briefly presented double masked faces exhibiting 7 basic emotions. Our hypotheses were that impaired semantic understanding of emotion words and low cognitive ability would yield lowest emotion recognition. SSD exhibited lower accuracy of emotion perception than controls (46.1% compared with 64.5%, p = 0.026), even when considering the unbiased hit rate (22.4% compared with 43%, Z = 2.62, p < 0.01). Raw data showed uncommon but significant misclassifications of fear as sad, disgust as sad, sad as happy and angry as surprise. Once guessing and presentation frequencies were considered, only overall accuracy differed between SSD and healthy controls. There were significant correlations between cognitive ability, antipsychotic dose, speed and emotion accuracy in the SSD group. In conclusion, that there were no specific emotion biases in the SSD group compared to healthy controls, but particular individuals may have greater impairments in facial emotion perception, being influenced by intellectual ability, psychomotor speed and medication dosages, rather than specifically emotion word understanding. This implies that both state and trait factors influence emotion perception in the aggressive SSD group and may reveal one source of potential misunderstanding of social situations which may lead to boundary violations and aggression.

Psychopathy-associated personality traits influence crime-scene behavior in male homicide offenders.

Purpose: We investigated whether psychopathy-associated personality traits and behavioral styles affect the manner in which homicides are committed or the motives underlying them. Materials and methods: Using three nationwide registries and an in-house homicide database based on court verdicts, we identified all cases of homicide in Sweden during the years 2007, 2008 and 2009. In 72 male offenders who had undergone assessment using the Psychopathy Checklist - Revised (PCL-R), the manner of homicide was categorized as instrumental or expressive, and the motive as belonging to one of five categories: (1) intimate-partner or family-related homicide; (2) homicide occurring during altercations, (3) robberies or burglaries, or (4) criminal conflicts; or (5) sexual homicide. Results and conclusions: Offenders who had committed homicide in an instrumental manner or with a sexual motive had higher scores on PCL-R factor 1 than offenders displaying an expressive manner or other motives, suggesting that partially adaptive personality traits influence the crime-scene behavior of the former type of offenders more than maladaptive behavioral styles.

Psychometric Properties of the Swedish Version of the Brief Repetitive Thinking Questionnaire (RTQ-10): An Internet-Based Study on Degrees of Affective Symptoms and Levels of Distress.

INTRODUCTION: Repetitive negative thinking (RNT) is reported in a wide variety of emotional disorders, although it is most often associated with either depression or anxiety disorders, assessed as symptoms of rumination and worry. Early detection of indicators for RNT across disorders is needed. To this end we explored the psychometric properties of a transdiagnostic measure, i.e., the Swedish version of the brief Repetitive Thinking Questionnaire (RTQ-10), in adults (n = 674, age: 18 years or older). METHODS: Participants completed an online battery of questionnaires measuring RNT, anxiety, depression and levels of positive and negative affect, satisfaction with life, metacognitive beliefs, and sick leave. Reliability and validity were evaluated with Cronbach's α, item and scale correlations, factor analysis (including multigroup analysis), and multiple linear regression analysis. Principal component analysis and exploratory factor analysis were first carried out to identify the number of latent factors. Confirmatory factor analysis was then used to assess the model fit of a single latent factor. RESULTS: Analyses supported a single-factor solution. Results showed that the reliability was excellent. The single-factor model was robust, except across levels of distress that did not support scalar invariance. Negative metacognitive beliefs, negative affect, and anxiety were strong covariates demonstrating convergent validity. Negative and weaker correlations with life satisfaction, positive affect, and physical symptoms contributed to the discriminant validity. CONCLUSION: This study showed that the instrument is robust in a population with various degrees of affective symptoms and distress. These results provide additional psychometric support for the RTQ-10 as a transdiagnostic measure. It can be administered online to assess RNT as a risk factor for emotional disorders.

Self-reported violent ideation and its link to interpersonal violence among offenders with mental disorders and general psychiatric patients.

This study aims at comparing mentally disordered offenders and general psychiatric patients regarding violent ideation and at exploring its association with interpersonal violence. We recruited 200 detainees undergoing forensic psychiatric evaluation and 390 general psychiatric patients at discharge. At baseline, they were asked about violent ideation; at the 20-week follow-up, information about violent acts was gathered from crime conviction registry, interviews, and records. The lifetime prevalence of violent ideation was 32.5% for offenders and 35.6% for patients; the corresponding two-month prevalence was 22.5% and 21.0%, respectively. For the both samples combined, those with violent ideation in their lifetime were significantly more prone to commit violent acts during follow-up than those without such ideation, OR = 2.65. The same applied to the patient sample, OR = 3.41. In terms of positive predictive values, fewer than 25% of those with violent ideation committed violent acts. Contrary to our hypothesis, the prevalence of violent ideation did not differ significantly between offenders and patients. However, there was support for the hypothesized association between violent ideation and violent acts on a group level. On an individual level, the clinician should consider additional factors when assessing the risk for violent acts.

Dementia and cognitive disorder identified at a forensic psychiatric examination - a study from Sweden.

BACKGROUND: Few studies have addressed the relationship between dementia and crime. We conducted a study of persons who got a primary or secondary diagnosis of dementia or cognitive disorder in a forensic psychiatric examination. METHODS: In Sweden, annually about 500 forensic psychiatric examinations are carried out. All cases from 2008 to 2010 with the diagnoses dementia or cognitive disorder were selected from the database of the Swedish National Board of Forensic Medicine. Out of 1471 cases, there were 54 cases of dementia or cognitive disorder. Case files were scrutinized and 17 cases of dementia and 4 cases of cognitive disorder likely to get a dementia diagnosis in a clinical setting were identified and further studied. RESULTS: There were 18 men and 3 women; Median age 66 (n = 21; Range 35-77) years of age. Eleven men but no women had a previous criminal record. There were a total of 38 crimes, mostly violent, committed by the 21 persons. The crimes were of impulsive rather that pre-meditated character. According to the forensic psychiatric diagnoses, dementia was caused by cerebrovascular disorder (n = 4), alcohol or substance abuse (n = 3), cerebral haemorrhage and alcohol (n = 1), head trauma and alcohol (n = 2), Alzheimer's disease (n = 2), Parkinson's disease (n = 1), herpes encephalitis (n = 1) and unspecified (3). Out of four persons diagnosed with cognitive disorder, one also had delusional disorder and another one psychotic disorder and alcohol dependence. An alcohol-related diagnosis was established in ten cases. There were only two cases of Dementia of Alzheimer's type, one of whom also had alcohol intoxication. None was diagnosed with a personality disorder. All but one had a history of somatic or psychiatric comorbidity like head traumas, stroke, other cardio-vascular disorders, epilepsy, depression, psychotic disorders and suicide attempts. In this very ill group, the suggested verdict was probation in one case and different forms of care in the remaining 20 cases instead of prison. CONCLUSIONS: Few cases of dementia or cognitive disorder were identified by forensic psychiatric examinations. All but one suffered from a variety of serious mental and medical conditions affecting the brain. Alcohol abuse was prevalent.

Effects of 25 mg oxazepam on emotional mimicry and empathy for pain: a randomized controlled experiment.

Emotional mimicry and empathy are mechanisms underlying social interaction. Benzodiazepines have been proposed to inhibit empathy and promote antisocial behaviour. First, we aimed to investigate the effects of oxazepam on emotional mimicry and empathy for pain, and second, we aimed to investigate the association of personality traits to emotional mimicry and empathy. Participants (n=76) were randomized to 25 mg oxazepam or placebo. Emotional mimicry was examined using video clips with emotional expressions. Empathy was investigated by pain stimulating the participant and a confederate. We recorded self-rated experience, activity in major zygomatic and superciliary corrugator muscles, skin conductance, and heart rate. In the mimicry experiment, oxazepam inhibited corrugator activity. In the empathy experiment, oxazepam caused increased self-rated unpleasantness and skin conductance. However, oxazepam specifically inhibited neither emotional mimicry nor empathy for pain. Responses in both experiments were associated with self-rated empathic, psychopathic and alexithymic traits. The present results do not support a specific effect of 25 mg oxazepam on emotional mimicry or empathy.

Violent victimization and health service utilization in a forensic psychiatric context: a comparison between offenders with mental disorders and matched controls.

BACKGROUND: Offenders with mental disorders constitute a particularly exposed group in society, with high rates of morbidity, mortality, and social deprivation. Often thought of primarily as perpetrators, these individuals may also be subjected to violence. Previous research indicates that violent victimization during lifespan is a risk factor for violent perpetration among psychiatric patients, but victimization studies on the group of offenders with mental disorders are scarce. Health services are pivotal to this group, but although most individuals do utilize these services, their vulnerability seems to remain. This study aimed at exploring the rates of victimization and health service utilization, including perceptions of unmet health care needs, among offenders with mental disorders. METHODS: Two hundred detainees undergoing a forensic psychiatric evaluation in Stockholm were asked about violent victimization and health service utilization. Each detainee was compared with three controls from the general population, matched regarding age, sex, and occupation. RESULTS: Victimization during the past year was reported by 52.3% of the detainees and 11.1% of the controls, with a corresponding risk ratio of 8.2. Health service utilization during the past three months was reported by 47.7 and 23.7%, respectively (risk ratio 2.0); and unmet health care needs by 42.2 and 16.7%, respectively (risk ratio 3.4). There was no distinct association between victimization and health service utilization among detainees. CONCLUSIONS: Offenders with mental disorders are at great risk of being victimized, and they experience impediments to receiving requisite health care. A possible way to reduce victimization and improve health service utilization may be to establish interdisciplinary yet specialized health centers with outreach teams but without complicated referral procedures.

The effect of gender on the outcome of forensic psychiatric assessment in Sweden: A case vignette study.

BACKGROUND: Previous research suggests that female violent offenders at risk of a prison sentence are more likely than their male counterparts to be assessed as having mental health problems of a nature or degree that would lead to a court requirement for hospital treatment. AIMS/HYPOTHESES: To test the hypothesis that there is bias towards hospital disposal of female compared with male violent offenders with mental disorder. METHODS: In Sweden, the National Board of Forensic Medicine oversees all assessments of mental disorder for the criminal courts. Twenty-six Board appointed forensic psychiatrists, psychologists and social workers each independently assessed six case vignettes for fit with criteria for 'severe mental disorder', a prerequisite for hospital disposal from court. Each gender neutral vignette described a person who had been convicted of serious assault and had a major mental disorder. A gender was then assigned to each offender randomly within a block design, thus varying between sets. Participants were blind to the main aim of the study and the gender variation. RESULTS: There was no significant association between gender of the person assessed and judgement that s/he had a 'severe mental disorder'. An offender depicted as having mental retardation was more likely to be assessed as at high risk of criminal recidivism if portrayed as female, regardless of the sex, place of work or level of experience of the assessor. CONCLUSION: We found no evidence of gender bias in determining appropriateness of a hospital disposal of an offender with mental disorder. The difference in assessment of recidivism according to sex of the patient was only in relation to mental retardation; further research would be needed to able to interpret this. As researchers in other countries have reported gender bias in disposals from court, our findings may provide support for a centralised forensic psychiatric assessment board and formal, on-going training. Copyright © 2015 John Wiley & Sons, Ltd.

Reliability and Construct Validity of the Psychopathic Personality Inventory-Revised in a Swedish Non-Criminal Sample - A Multimethod Approach including Psychophysiological Correlates of Empathy for Pain.

Cross-cultural investigation of psychopathy measures is important for clarifying the nomological network surrounding the psychopathy construct. The Psychopathic Personality Inventory-Revised (PPI-R) is one of the most extensively researched self-report measures of psychopathic traits in adults. To date however, it has been examined primarily in North American criminal or student samples. To address this gap in the literature, we examined PPI-R's reliability, construct validity and factor structure in non-criminal individuals (N = 227) in Sweden, using a multimethod approach including psychophysiological correlates of empathy for pain. PPI-R construct validity was investigated in subgroups of participants by exploring its degree of overlap with (i) the Psychopathy Checklist: Screening Version (PCL:SV), (ii) self-rated empathy and behavioral and physiological responses in an experiment on empathy for pain, and (iii) additional self-report measures of alexithymia and trait anxiety. The PPI-R total score was significantly associated with PCL:SV total and factor scores. The PPI-R Coldheartedness scale demonstrated significant negative associations with all empathy subscales and with rated unpleasantness and skin conductance responses in the empathy experiment. The PPI-R higher order Self-Centered Impulsivity and Fearless Dominance dimensions were associated with trait anxiety in opposite directions (positively and negatively, respectively). Overall, the results demonstrated solid reliability (test-retest and internal consistency) and promising but somewhat mixed construct validity for the Swedish translation of the PPI-R.

Boldness and its relation to psychopathic personality: Prototypicality analyses among forensic mental health, criminal justice, and layperson raters.

Research on psychopathic personality has been dominated by a focus on criminality and social deviance, but some theoretical models argue that certain putatively adaptive features are important components of this construct. In 3 samples (forensic mental health practitioners, probation officers and a layperson community sample), we investigated adaptive traits as conceptualized in the Triarchic model of psychopathy (Patrick et al., 2009), specifically the relevance of boldness to construals of psychopathic personality. Participants completed prototypicality ratings of psychopathic traits, including 3 items created to tap components of boldness (Socially bold, Adventurous, Emotionally stable), and they also rated a series of attitudinal statements (e.g., perceived correlates of being psychopathic, moral judgments about psychopaths). The composite Boldness scale was rated as moderately to highly prototypical among forensic mental health practitioners and probation officers and positively associated with other theoretically relevant domains of psychopathy. Across samples, higher composite Boldness ratings predicted greater endorsement of adaptive traits (e.g., social skills) as characteristic of psychopathy. For the individual items, Socially bold was rated as highly prototypical and was associated with theoretically relevant correlates. Adventurous also was seen as prototypical, though to a lesser degree. Only forensic mental health practitioners endorsed Emotionally stable as characteristic of psychopathy. Our results provide partial support for the contention that the boldness concept is viewed as an important component of psychopathy, particularly among professionals who work directly with offender populations. (PsycINFO Database Record

Risk assessments and recidivism among a population-based group of Swedish offenders sentenced to life in prison.

BACKGROUND: In Sweden, the number of people serving life sentences has steadily increased. To date, few studies have examined the recidivism rate or the predictive validity of different risk assessment instruments in this group. AIMS: Our aim was to test the predictive validity among inmates serving life sentences of two different instruments used for assessing risk--the Historical, Clinical and Risk Management-20 (HCR-20), most widely used in clinical populations, and the Psychopathy Checklist-Revised (PCL-R), commonly applied in both penal and clinical settings. METHOD: Ninety-eight life-sentenced prisoners were included, 26 of whom were released during the study period. Data on risk assessments and dates for release were collected from administrative records, while recidivism data were retrieved from a national database on criminal convictions. RESULTS: Sex offenders obtained the highest scores and inmates charged with domestic violent offences obtained the lowest scores on both instruments. The released prisoners were followed for a mean period of 33 months. During this time five prisoners (19%) reoffended, four of them violently, with an average time to recidivism of 10 months. Only PCL-R Facet 4, which reflects antisocial features, was significantly associated with recidivism. CONCLUSIONS: This small, but population-based, study demonstrates that antisocial behaviour shows incremental predictive validity for reoffending among life-sentenced offenders, but other measures have little to add for this specific task. The fact that those life sentenced prisoners who reoffended did so so soon after release should prompt allocation of earlier interventions towards preventing this.

Mental Health Services and Public Safety: Substance Abuse Outpatient Visits Were Associated with Reduced Crime Rates in a Swedish Cohort.

Substance abuse is related to offending and substance abuse treatment has been associated with reductions in criminal behavior. This cohort study aimed to explore the relationship between participation in substance abuse interventions and general criminal recidivism among offenders with a combination of mental health problems and substance use problems. In total, 150 Swedish offenders with self-reported mental health and substance use problems were followed for approximately three years with regard to participation in substance abuse interventions and criminal recidivism. Participants with at least three planned visits to specialized outpatient substance abuse clinics had a substantially reduced risk of reoffending as compared to those with fewer than three such visits (HR = 0.47, 95% CI 0.29-0.77). For those with at least three planned visits, general criminal recidivism was reduced by 75% during periods of participation in outpatient visits, as compared to periods of non-participation (HR = 0.25, 95% CI 0.11-0.60). For offenders with mental health problems and substance use problems, outpatient substance abuse interventions could be regarded as important from a clinical risk management perspective, and be encouraged.

Unsolved homicides in Sweden: A population-based study of 264 homicides.

The clearance rates for homicides have decreased internationally. This retrospective population-based study of all Swedish homicide incidents between 2007 and 2009 (n=264) aims to investigate factors associated with solvability in homicides. Victims were identified in an autopsy registry and offenders in a criminal-conviction registry. Autopsy reports, police files, court verdicts and criminal records were systematically collected and linked. The clearance rate was 86.4% (n=228), and almost three quarters of cases (71.9%) were solved within the first week. Nine factors were significantly associated with the case status; however, only four factors remained significant in the multivariate logistic-regression model. Cases were more likely to be solved if there was an eyewitness and if the victim was intoxicated with alcohol. Moreover, cases were less likely to be solved if the victim had a criminal record in the past five years and was killed by a firearm. In the final model, a Cox proportional-hazards model, where time to arrest was taken into account, only alcohol intoxication were positively and firearms negatively significantly associated with clearance status. The study concludes that cases involving these factors should be granted extra, intensive and lasting resources.