Familicide: A Systematic Literature Review.

Familicides have received relatively little attention and are mostly discussed in studies with broader aims. Here, we reviewed 67 studies from 18 countries on familicides, in which an offender killed or attempted to kill their current or former spouse/intimate partner and one or more of their biological or stepchildren. We conducted a systematic literature search in PubMed, PsycINFO, and Google Scholar. Eight studies investigated familicide specifically, while the remaining reported on familicide cases as a subsample. We retrieved data on offenders' gender, age, and background as well as on victims and their relationship to the offender. We also retrieved data on contextual factors and offense characteristics (i.e., modus operandi, offense location, premeditation, and whether or not the offender had committed suicide). We also coded methodological aspects of the studies. Familicides were almost exclusively committed by men and about half of the familicide cases led to the suicide of the offender. Mental health problems, relationship problems, and financial difficulties were prevalent. Because few studies reported population base rates of the investigated characteristics, it is difficult to draw conclusions about specific risk factors. Future research should further investigate typologies of familicide and examine risk factors for different types of familicides.

Substance Abuse and Excessive Mortality Among Forensic Psychiatric Patients: A Finnish Nationwide Cohort Study.

Background: Forensic psychiatric patients are known to have reduced life expectancy. The aim of this study was to explore to what extent substance abuse disorders account for this increased mortality. Methods: Data up to December 31, 2016 for mortality (causes of death register) and substance abuse (forensic psychiatric examinations) were collected for all of the 950 patients committed to involuntary forensic psychiatric hospital care in Finland during 1980-2009 and discharged no later than December 31, 2016. Patients were then classified as suffering or not suffering from substance abuse disorders and their causes of death were examined. The standardized mortality ratio was then calculated for these groups on the basis of sex-, age-, and calendar-period-specific mortality rates for the general Finnish population. Results: During the follow-up time (mean 13.4 years), 354 (320 men, 34 women) patients died, resulting in a standardized mortality ratio of 3.5. The standardized mortality ratio for the patients with a history of substance abuse disorders was 4.1 compared to 2.8 for those with no such history. Among men, but not women, the age-adjusted proportion of death was significantly higher for those with a history of substance abuse disorders. In addition, in patients with a history of substance abuse disorders, the male age-adjusted competing risk of mortality was higher for unnatural causes, but not natural causes. Furthermore, a prominent proportion (16%) of all deaths and a majority of the accidental deaths (64%) occurred under the influence of some substance. Conclusions: Substance abuse is a major factor causing excessive mortality among forensic psychiatric patients. The management of substance abuse problems should be one cornerstone of the treatment of patients with both severe mental disorders and substance abuse disorders during their time in hospital and this should be extended to outpatient care.

Exploring a new structured professional judgment measure (impulsivity measure related to violence) after an average follow-up of 10 years: A study of Finnish offenders.

BACKGROUND: Identification of the risk factors underlying impulsivity related to violent acts is an essential component of risk assessment and management to reduce violent offending. AIMS: Our aim was to develop a clinically useful measure for assessing impulsivity related to violence. Our research questions were which items in the newly developed measure are associated with later violent recidivism and what is the measure's predictive validity? METHODS: A new scale, the impulsivity measure related to violence (IMP-V), was studied by completing the scale, blind to outcome, from information in the forensic psychiatric examination reports of 63 of a 1-year referral cohort of 181 Finnish offenders. Data on reoffending for up to 15 years after release were collected from official criminal records. RESULTS: The predictive accuracy of the IMP-V continuous ratings was 78% and for the categorical summary risk ratings 77%. Univariate analyses of categorical summary risk ratings of the risk factors revealed that, with two exceptions, each additional score on the IMP-V was associated with a significant increase in violence recidivism. CONCLUSIONS: These preliminary results indicate that the IMP-V is a promising decision-enhancing guide for assessing the risk of violence in impulsive people and that the measure is worth developing for use with impulsivity-prone offenders and forensic psychiatric patients. The IMP-V organises information on the nature of impulsivity in violence-prone persons and thus also creates opportunities for more effective risk management.

Repeated neonaticide: differences and similarities to single neonaticide events.

This study aims to identify differences between single and repeat perpetrators of filicide by using register-based data. The study used register-based, comprehensive, nationwide data from both Austria and Finland. The current study covers 23 perpetrators, 20 single and 3 repeat perpetrators, with a total of 28 victims. All victims had a maximum age of 24 h and all perpetrators were women. Every third victim of neonaticide was a victim of a repeat case. The repeat perpetrators were older; had a higher number of children over their lifespan, some of whom lived with them; were more likely to live within established family structures; had higher levels of education and employment; had a higher proportion of personality disorders; and were more likely to identify stress factors during pregnancy. One unexpected finding was low levels of awareness about pregnancy within the perpetrator's circle remain a risk factor, especially for repeat perpetrators. Arguably, the quality of interpersonal relationships these women have may be affected by their own mental health issues and life experience and vice versa.

Cause-specific mortality in Finnish forensic psychiatric patients.

PURPOSE: To analyze the causes of mortality among patients committed to compulsory forensic psychiatric hospital treatment in Finland during 1980-2009 by categorizing the causes of mortality into somatic diseases, suicides and other unnatural deaths. MATERIALS AND METHODS: The causes of mortality were analyzed among 351 patients who died during the follow-up. Standardized mortality ratio (SMR) was calculated as the ratio of observed and expected number of deaths by using the subject-years methods with 95% confidence intervals, assuming a Poisson distribution. The expected number of deaths was calculated on the basis of sex-, age- and calendar-period-specific mortality rates for the Finnish population. RESULTS: The vast majority (249/351) of deaths were due to a somatic disease with SMR of 2.6 (mean age at death 61 years). Fifty nine patients committed suicide with a SMR of 7.1 (mean age at death 40 years). Four patients were homicide victims (mean age at death 40 years) and 32 deaths were accidental (mean age at death 52 years). The combined homicides and accidental deaths resulted in a SMR of 1.7. CONCLUSIONS: The results of this study point out that the high risk for suicide should receive attention when the hospital treatment and the outpatient care is being organized for forensic psychiatric patients. In addition, the risk of accidents should be evaluated and it should be assured that the patients receive proper somatic healthcare during the forensic psychiatric treatment and that it continues also in the outpatient setting.

Forensic Psychiatric Patients' Perspectives on Their Care: A Narrative View.

PURPOSE: The purpose of this study is to describe forensic psychiatric patients' experiences of and perspectives on forensic psychiatric treatment. DESIGN AND METHODS: Eight forensic psychiatric patients were interviewed, and the resultant research material was analyzed by narrative analysis. FINDINGS: Patients' narratives contain different themes telling different things and the personnel need to pay attention to these. PRACTICE IMPLICATIONS: The findings of the present study should direct the forensic psychiatric personnel's attention to the notion that forensic psychiatric patients' experiences of their treatment can improve the quality of patient-centered care and reduce bureaucracy.

The Offense as Perceived by the Parents of Forensic Psychiatric Patients.

This study aims to describe the views of forensic psychiatric patients' parents, and especially how they feel about the patient's offense. The data analyzed was collected by interviews with forensic psychiatric patients' parents and analyzed by inductive content analysis. The findings suggest that the offense committed has a significant effect on the lives of parents of forensic psychiatric patients and in many ways these people felt like a marginalized group even though they were frequently a major resource for their child who had been taken into forensic psychiatric care. The parents of a forensic psychiatric patient have a prominent role in the life of the patient and this role and the parents' coping should also be supported by the forensic psychiatric treatment system.

The Therapeutic Approach to a Patient's Criminal Offense in a Forensic Mental Health Nurse-Patient Relationship-The Nurses' Perspectives.

PURPOSE: The purpose of this study is to describe the therapeutic approach to a patient's criminal offense in a forensic mental health nurse-patient relationship from the nurse's perspective. DESIGN AND METHODS: Eight nurses in a Finnish forensic psychiatric hospital were interviewed, and the resultant research material was analyzed by inductive content analysis. FINDINGS: The results revealed the process of the therapeutic approach to a patient's offense, which comprises numerous steps and various phases. PRACTICE IMPLICATIONS: For the nurse, the process of working through the offense can be divided into stages in which an attempt is made to respond to the patient's behavior and interaction in a manner that leads to working through the criminal act.

Is there an interrelationship between the effects of antipsychotics on psychopathology and on metabolism?

BACKGROUND: Increased body weight and hyperlipidemia caused by antipsychotics may be associated with improved antipsychotic efficacy in schizophrenia. If this association has a causal interrelationship via a genuine pathophysiological mechanism, then body weight loss in antipsychotic-treated patients would be accompanied by worsened psychopathology. This could have clinical implications. AIM: To explore whether the decreased body weight in these patients is associated with a worsened psychopathology. METHODS: In our previously published study, a 16 week treatment period with add-on orlistat (but not placebo) resulted in body weight loss in male (but not female) clozapine- or olanzapine-treated overweight or obese patients. In the current study, we investigated whether body weight loss in those male patients could worsen psychosis. Changes in the Positive and Negative Syndrome Scale (PANSS) scores within groups and body weight changes and lipid profiles over the treatment period were analysed by the paired samples t-test. Between-group comparisons were analysed by the independent samples t-test. RESULTS: Over the treatment period body weight decreased by 2.56 ± 3.25 kg from initial 106.02 ± 12.61 kg (p = 0.04) for the orlistat group, with no statistically significant changes for the placebo group. Lipid levels did not change in either group. The orlistat-induced weight decrease was not associated with worsening in the PANSS scores. CONCLUSIONS: Weight loss was not associated with a worsening of psychosis. The interrelationship between the antipsychotic-induced weigh gain and improved schizophrenia psychopathology observed in earlier studies appears to be indirect. Orlistat treatment in our study did not worsen psychopathology in this population.

Forensic psychiatric patients' narratives of their offense.

This study aims to describe forensic psychiatric patients' experiences of their offense and its meaning for their lives, and to increase the understanding of the meaning of the offense in the eyes of the patient. The data analyzed was collected by interviews with forensic psychiatric patients and analyzed by narrative analysis. The findings suggest that forensic psychiatric patients have different types of stories describing the offense and its meaning in their lives. Illness narratives can be utilized therapeutically because they may construct patients' identity, experiences, and their situation as people with an illness seek explanations and meanings for their plight.

Mortality among forensic psychiatric patients in Finland.

BACKGROUND: Both mental illness and criminality are associated with higher risk of early death, yet the mortality among forensic psychiatric patients who are affected by both mental illness and criminal behaviour has scarcely been studied. AIMS: To analyse the mortality among all patients who were committed to a compulsory forensic psychiatric hospital treatment in Finland between 1980 and 2009. Mortality was analysed according to the age when the patient was committed to forensic treatment. RESULTS: A total of 1253 patients were included, of which 153 were females and 1100 were males. The mean follow-up time in this study was 15.1 years, and 351 (28%) had died during the follow-up period. The standardized mortality rate (SMR) for the whole study group was 2.97 (95% CI 2.67-3.29). Among females the SMR was 3.62 (95% CI 2.57-5.09), and among males 2.91 (95% CI 2.61-3.25). The SMRs were higher when patients were committed to forensic treatment before the age of 40 years. CONCLUSION: This study showed an increased mortality among forensic psychiatric patients compared with the general population and the mortality was inversely proportional to the age when the treatment had begun. In contrast to the earlier studies, the mortality in this study was lower indicating that prolonged treatment may have an overall protective effect on forensic psychiatric patients.

Methodological and ethical challenges in studying patients' perceptions of coercion: a systematic mixed studies review.

BACKGROUND: Despite improvements in psychiatric inpatient care, patient restrictions in psychiatric hospitals are still in use. Studying perceptions among patients who have been secluded or physically restrained during their hospital stay is challenging. We sought to review the methodological and ethical challenges in qualitative and quantitative studies aiming to describe patients' perceptions of coercive measures, especially seclusion and physical restraints during their hospital stay. METHODS: Systematic mixed studies review was the study method. Studies reporting patients' perceptions of coercive measures, especially seclusion and physical restraints during hospital stay were included. Methodological issues such as study design, data collection and recruitment process, participants, sampling, patient refusal or non-participation, and ethical issues such as informed consent process, and approval were synthesized systematically. Electronic searches of CINALH, MEDLINE, PsychINFO and The Cochrane Library (1976-2012) were carried out. RESULTS: Out of 846 initial citations, 32 studies were included, 14 qualitative and 18 quantitative studies. A variety of methodological approaches were used, although descriptive and explorative designs were used in most cases. Data were mainly collected in qualitative studies by interviews (n = 13) or in quantitative studies by self-report questionnaires (n = 12). The recruitment process was explained in 59% (n = 19) of the studies. In most cases convenience sampling was used, yet five studies used randomization. Patient's refusal or non-participation was reported in 37% (n = 11) of studies. Of all studies, 56% (n = 18) had reported undergone an ethical review process in an official board or committee. Respondents were informed and consent was requested in 69% studies (n = 22). CONCLUSIONS: The use of different study designs made comparison methodologically challenging. The timing of data collection (considering bias and confounding factors) and the reasons for non-participation of eligible participants are likewise methodological challenges, e.g. recommended flow charts could aid the information. Other challenges identified were the recruitment of large and representative samples. Ethical challenges included requesting participants' informed consent and respecting ethical procedures.

Psychiatric staff on the wards does not share attitudes on aggression.

BACKGROUND: The concept of ward culture has been proposed as a reason for the often reported differences in treatment decisions when managing inpatient aggression. We therefore studied whether staff on wards actually shares similar perceptions and attitudes about aggression and whether the specialty of the ward on which the staff members work influences these opinions. METHODS: The Attitudes Towards Aggression Scale was used to assess attitudes towards aggression in 31 closed psychiatric wards. Altogether 487 staff members working on the study wards were asked to fill in the scale. Respondent's gender, age, educational level, working experience on the current ward, and specialty of this ward (acute, forensic, rehabilitation) served as background variables. RESULTS: Most of the variance found was due to differences between individuals. Belonging to the personnel of a particular ward did not explain much of the variance. CONCLUSIONS: Psychiatric staff on the wards does not share attitudes on aggression. As each staff member has his/her own opinion about aggression, training for dealing with aggression or violent incidents should be done, at least partly, on an individual level. We also suggest caution in using the concept of ward culture as an explanation for the use of restrictive measures on psychiatric wards.

Does experienced seclusion or restraint affect psychiatric patients' subjective quality of life at discharge?

BACKGROUND: In Finland major effort has been invested in reducing the use of coercion in psychiatric treatment, and the goal is to diminish the use of coercion by 40% by 2015. Improving patients' quality of life (QoL) has gained prominence in psychiatric treatment during the past decade. Numerous studies have shown that most secluded or restrained patients (S/R patients) would prefer not to have had this experience. Experience of S/R could affect negatively patients' QoL, but empirical data on this issue are lacking. AIM: The study aimed to explore the effect of experienced S/R on the subjective QoL of psychiatric in-patients. METHOD: This study explored subjective QoL of the S/R patients. At discharge, S/R patients completed the Short Form of the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q-SF). RESULTS: We found that S/R patients' (n = 36) subjective QoL was significantly better than that of non-S/R patients' (n = 228). Most non-S/R patients were diagnosed with mood disorders (mostly depression). Most of S/R patients were diagnosed with schizophrenia, schizotypal and delusional disorders. The mean duration of S/R was 2.3 days, median was one day and mean length of the hospitalization after S/R episode was 2.5 months. CONCLUSION: Our cross-sectional findings suggest that S/R does not considerably influence patients' QoL or that the influence is short-lived. Because baseline QoL was not measured this remains uncertain. There are also many other factors, such as negative mood, which decrease the patients' QoL ratings. These factors may either mask the influence of S/R on QoL or modify the experience of QoL to such an extent that no independent association can be found at the time of discharge.

Influence of patient characteristics on duration of seclusion/restrain in acute psychiatric settings in Japan.

AIM: The aim of this study was to investigate the current state of duration of seclusion/restraint in acute psychiatric settings in Japan and the effect of patient characteristics on duration of seclusion/restraint. METHODS: During an 8-month period starting from November 2008, duration of seclusion/restraint and patient characteristics were investigated in 694 psychiatric inpatients who experienced seclusion/restraint in three emergency and three acute wards at four psychiatric hospitals. Reasons for starting seclusion/restraint were also assessed. Analysis was performed using generalized linear models, with the duration of seclusion/restraint as the dependent variable and patient characteristics and reasons for starting seclusion/restraint as independent variables. RESULTS: Of the patients secluded/restrained, 58.6% had a primary diagnosis of schizophrenia (F20-F29) and a large proportion (37.9%) were secluded/restrained due to hurting others. Median hours ofseclusion/restraint were 204 and 82 h, respectively. The duration of seclusion was longer for patients with F20-F29 than those with disorders due to psychoactive substance use (F10-F19) or other diagnoses (F40-F99), and when the reason was danger of hurting others. In contrast, the duration of restraint in female patients and in patients with F10-F19 diagnosis was shorter. CONCLUSION: The duration of seclusion/restraint at acute psychiatric care wards in Japan are much longer than those reported by previous overseas studies. Although Japanese structure issues such as more patients per ward and a lower ratio of nurses need to be considered, skills for dealing with patients with primary diagnosis of F20-F29 secluded due to danger posed to others should be improved.

Substance-induced psychoses converting into schizophrenia: a register-based study of 18,478 Finnish inpatient cases.

BACKGROUND: Despite the clinical importance of substance-induced psychosis (SIP), few studies have examined the course of this condition after its acute manifestation. OBJECTIVE: To investigate the rate of SIP conversion to a schizophrenia spectrum disorder and the length of follow-up needed to catch the majority of these patients whose diagnoses change. In addition to the conversion rate and pattern, we wanted to look for possible related factors. METHOD: Using the nationwide Finnish Hospital Discharge Register, we followed all patients (N = 18,478) since their first inpatient hospital admission with a diagnosis of SIP (codes 2921 and 2928 in DSM-III-R and codes F10-F19 in ICD-10 with a third digit of 4, 5, or 7) between January 1987 and December 2003 in Finland. Patients (mean age = 43.7 years, standard deviation = 13.5 years) were followed until first occurrence of schizophrenia spectrum disorder, death, or the end of December 2003, whichever took place first. Conversions of discharge diagnoses into schizophrenia spectrum disorders (codes 2951-2959 and 2971 in DSM-III-R and codes F20, F22, and F23 in ICD-10) were recorded at follow-up. RESULTS: Eight-year cumulative risk to receive a schizophrenia spectrum diagnosis was 46% (95% CI, 35%-57%) for persons with a diagnosis of cannabis-induced psychosis and 30% (95% CI, 14%-46%) for those with an amphetamine-induced psychosis. Although alcohol-induced psychosis was the most common type of SIP, 8-year cumulative risk for subsequent schizophrenia spectrum diagnosis was only 5.0% (95% CI, 4.6%-5.5%). No differences were detected with regard to gender, except for amphetamine-induced psychosis, which converted into a schizophrenia spectrum disorder significantly more often in men (P = .04). The majority of conversions to a schizophrenia spectrum diagnosis occurred during the first 3 years following the index treatment period, especially for cannabis-induced psychosis. CONCLUSION: Substance-induced psychotic disorders predict schizophrenia spectrum disorders to a greater extent than previously thought. The intensity of clinical attention focused on substance-induced psychotic disorders should be increased.

Secluded and restrained patients' perceptions of their treatment.

Though some empirical and anecdotal accounts can be located in the extant literature, it remains the case that little is known about how secluded/restrained (S/R) patients perceive their overall treatment. The purpose of this study was to explore patients' perceptions of their hospital treatment measured after S/R. The data were collected with a Secluded and Restrained Patients' Perceptions of their Treatment (S/R-PPT) questionnaire from S/R patients aged 18-65 years. Ninety completed questionnaires were analysed. Patients perceived that they received enough attention from staff, and they were able to voice their opinions, but their opinions were not taken into account. Patients denied the necessity and beneficence of S/R. Women and older patients were more critical than men and younger patients regarding the use of restrictions. There were also statistically-significant differences in responses among patients at different hospitals. It is concluded that patients' opinions need more attention in treatment decisions. To achieve this, psychiatric treatment needs genuine dialogue between patients and staff, and individual care should have alternatives and no routine decisions. Therefore, the treatment culture must improve towards involving patients in treatment planning, and giving them a say when S/R is considered.

Mechanical restraint in adolescent psychiatry: a Finnish Register study.

BACKGROUND: Little is known of the use of mechanical restraint in adolescent psychiatry. AIMS: To investigate the frequency and features of mechanical restraint in the field of Finnish adolescent psychiatry. METHODS: The data were collected in the metropolitan area of Helsinki, Finland, with seven closed and eight open wards for Finnish-speaking 13-17-year-old adolescents. The official restraint reports and the hospital files of the restraint patients from January 2009 to December 2009 were collected and analyzed. RESULTS: Among adolescents hospitalized in closed wards, the 1-year prevalence of mechanical restraint was 9.5%. Among all hospitalized adolescents, the prevalence was 6.9%. The number of mechanically restrained individuals per 100,000 13 to 17-year -old Finnish-speaking inhabitants was 57.1. The median duration of the restraint episode was 4 h and 50 min, but almost half of the mechanical restraint episodes lasted 8 h or more. A quarter of restraint episodes were not based on reasons mentioned in the Finnish Mental Health Act. The most frequent diagnostic categories of mechanically restrained adolescents were mood disorders followed by schizophrenia-related as well as behavioral and emotional disorders. Suicidality preceded 40% and violence 61% of restraint episodes. Boys were restrained during the first days of hospital treatment significantly more often than were girls, whereas one in four girls experienced her first episode of restraint after 1 month of hospitalization. CONCLUSIONS: Reducing the number and shortening the length of mechanical restraint episodes requires education of staff as well as projects focusing on reducing coercion. The clinical guidelines must be followed at grassroots level.

In a randomized placebo-controlled add-on study orlistat significantly reduced clozapine-induced constipation.

Constipation is a common and potentially fatal side effect of clozapine treatment. Another important side effect of clozapine may also be significant weight gain. Orlistat is a weight-control medication that is known to induce loose stools as a common side effect. This study aimed to explore whether orlistat used to control clozapine-induced weight gain can simultaneously tackle clozapine-related constipation. In this 16-week randomized-controlled study, clozapine-treated patients received add-on orlistat (n=30) or add-on placebo (n=24). Colonic function was measured using the Bristol Stool Form Scale. There was a significant (P=0.039) difference in the prevalence of constipation in favor of orlistat over placebo in completers (n=40) at the endpoint. A decrease in the prevalence of constipation within the orlistat group (P=0.035) was observed (vs. no statistically significant changes in the placebo group). In clozapine-treated patients, orlistat may be beneficial not only for weight control but also as a laxative. As no established treatments for clozapine-induced constipation exist, orlistat can be considered for this population, although more studies are required.