Criminal behavior in alcohol-related dementia and Wernicke-Korsakoff syndrome: a Nationwide Register Study.

BACKGROUND: Chronic heavy alcohol use may lead to permanent brain damage, cognitive impairment, and dementia. While the link between alcohol use and crime is strong, virtually no research exists on the criminal behavior of patients with the alcohol-related neurocognitive disorders of Wernicke-Korsakoff syndrome (WKS) and alcohol-related dementia (ARD). METHODS: The study population included all persons diagnosed with WKS (n = 1149) or ARD (n = 2432) in Finland in 1998-2015. Data on diagnoses, mortality, and crime were obtained from Finnish nationwide registers. Crime incidences were calculated 4 years before and after diagnosis. Crime types, incidences, and mortality were compared between disorders and with the general population. RESULTS: Altogether 35.6% of WKS patients and 23.6% of ARD patients had committed crimes in the 4 years preceding diagnosis, most commonly property and traffic crimes, followed by violent crimes. The incidence of criminal behavior decreased significantly after diagnosis; in WKS patients, the standardized criminality ratio (SCR), the ratio of observed to expected number of crimes (95% CI), was 3.91 (3.72-4.10) in 4 years before and 2.80 (2.61-3.00) in 4 years after diagnosis. Likewise, in ARD patients, the SCRs were 2.63 (2.51-2.75) before and 0.84 (0.75-0.92) after diagnosis. No significant difference emerged in mortality between persons with and without a criminal history. CONCLUSIONS: Persons with alcohol-related neurocognitive disorders frequently engage in criminal behavior prior to diagnosis, especially multiple offending. In the 4 years before and after diagnosis, crime rates declined in a linear fashion, with a marked reduction after diagnosis.

Suicides in degenerative neurocognitive disorders and traumatic brain injuries.

BACKGROUND: Neuropsychiatric symptoms in major neurocognitive disorders have been strongly associated with suicidality. METHODS: The objectives were to explore suicide rates in degenerative neurocognitive disorders (DNDs), alcohol-related neurocognitive disorders (ARNDs), and traumatic brain injuries (TBIs). Patients who received these diagnoses between 1998 and 2015 (N = 231,817) were identified from nationwide registers, and their mortality was followed up until December 31, 2018. We calculated incidences of suicides per 100,000 person-years, types of suicides, and suicide rates compared with the general population (standardized mortality ratio [SMR]). RESULTS: During the follow-up, 0.3% (95% confidence interval [95% CI]: 0.2-0.5) of patients with DNDs, 1.1% (0.7-1.8) with ARNDs, and 1.0% (0.7-1.3) with TBIs committed suicide. Suicide mortality rate was higher in men (58.9, 51.3, to 67.4 per 100,000) than in women (9.8, 7.5, to 12.5 per 100,000). The highest suicide rate was in ARNDs (98.8, 65.1, to 143.8 per 100,000), followed by TBIs (82.0, 62.4, to 105.8 per 100,000), and DNDs (21.2, 18.3, to 24.5 per 100,000). The SMRs (95% CI) were 3.69 (2.53-5.38), 2.99 (2.31-3.86), and 1.31 (1.13-1.51), respectively, and no sex difference emerged. The most common cause of death was self-inflicted injury by hanging or drowning (12.4, 10.3, to 14.8 per 100,000). CONCLUSIONS: Suicide rates were higher in all three patient groups than the general population. Suicide risk remained elevated for more than 10 years after diagnosis. The suicide methods were mostly violent.

Prospective study of antidepressant treatment of psychiatric patients with depressive disorders: treatment adequacy and outcomes.

BACKGROUND: Despite numerous national depression care guidelines (DCGs), suboptimal antidepressant treatment may occur. We examined DCG concordance and depression treatment outcomes in psychiatric settings. METHODS: We evaluated treatment received and outcomes of 128 psychiatric out- and inpatients participating in the PEGAD (Pharmacoepidemiology and Pharmacogenetics of Antidepressant Treatment for Depressive Disorders) study at baseline, two weeks, and eight weeks using interviews and questionnaires. Inclusion criteria were ICD-10 diagnosis of a depressive disorder, a Patient Health Questionnaire-9 symptom (PHQ-9) score ≥ 10, and a new antidepressant prescribed. The primary outcome of the study was within-individual change in PHQ-9 scores. RESULTS: At baseline, patients had predominately recurrent (83%) and in 19% treatment-resistant depression (TRD). The median preceding duration of the current episode was 6.5 months. At eight weeks, 85% of the patients (n = 107) used a DCG-concordant antidepressant dose. However, due to the scarcity of antidepressant combinations and augmentations, fewer TRD than non-TRD patients (25% vs. 84%, p < 0.005) received adequate antidepressant treatment. Additionally, one-third of the patients received inadequate follow-up. Overall, only 53% received treatment compatible with DCG recommendations for adequate pharmacotherapy and follow-up. The mean decline in PHQ-9 scores (-3.8 ± SD 5.7) was significant (p < 0.0005). Nearly 40% of the patients reached a subthreshold level of depression (PHQ-9 < 10), predicted by a lower baseline PHQ-9 score, recurrent depression, and female sex. However, 45% experienced no significant clinical improvement (PHQ-9 score reduction < 20%). CONCLUSIONS: Our findings suggest that inadequate treatment continues to occur in psychiatric care settings, particularly for TRD patients.

Antipsychotic Use and Mortality in Persons with Alcohol-Related Dementia or Wernicke-Korsakoff Syndrome: A Nationwide Register Study in Finland.

BACKGROUND: Research on the use of psychotropic drugs in people with alcohol-related neurocognitive disorders is virtually nonexistent. We examined the prevalence of antipsychotic drug use and its effect on mortality among patients with Wernicke-Korsakoff syndrome (WKS) or alcohol-related dementia (ARD). METHODS: In this nationwide register study, we collected data on the medication use and mortality of all persons aged ≥40 diagnosed with WKS (n = 1149) or ARD (n = 2432) between 1998 and 2015 in Finland. We calculated the prevalence of antipsychotic use within one year of diagnosis and the adjusted cumulative mortality of antipsychotic users versus non-users in relation to the age-, sex-, and calendar year-matched general population. RESULTS: Of the WKS and ARD patients, 35.9% and 38.5%, respectively, purchased one or more antipsychotic drugs in the year following diagnosis. The adjusted cumulative mortality of the antipsychotic users was significantly lower than that of non-users in both the WKS and ARD groups, where the adjusted hazard ratios (95% CI) were 0.85 (0.72-0.99) and 0.73 (0.65-0.81), respectively. WKS and ARD patients using antipsychotics were less likely to die of alcohol-related causes than antipsychotic non-users, but the difference was significant only in the ARD group. CONCLUSIONS: This population-based study shows that antipsychotic use is common in patients with WKS or ARD. In contrast to other dementia studies, our results indicate that the mortality of antipsychotic users is significantly lower than that of non-users. The lower mortality could be explained by decreased alcohol use and better healthcare coverage in antipsychotic users.

Criminal Behaviour After Diagnosis of a Neurocognitive Disorder: A Nationwide Finnish Register Study.

OBJECTIVE: To explore criminal behavior of individuals with Alzheimer's disease (AD), frontotemporal dementia (FTD), or Lewy body dementias (LBD) after the diagnosis. DESIGN: Nationwide register study. SETTING: Information on diagnoses and criminality was received from Finnish registers. Crime types and incidences were compared between disorders and the general population. PARTICIPANTS: All Finnish individuals diagnosed with AD, LBD, or FTD (n = 92 189) during 1998-2015. MEASUREMENTS: Types of crimes and incidences, the standardized criminality ratio (SCR, number of actual crimes per number of expected crimes), numbers of observed cases, and person-years at risk counted in 5-year age groups and for both sexes and yearly. RESULTS: Among men, at least one crime was committed by 2.8% of AD, 7.2% of FTD, and 4.8% of LBD patients. Among women, the corresponding figures were 0.4%, 2.0%, and 2.1%. The most frequent type of crime was traffic offence, followed by property crime. After age adjustment, the relative number of crimes between groups did not differ, except that men with FTD and LBD committed more crimes than those with AD. The SCR (95% CI) among men were 0.40 (0.38-0.42) in AD, 0.45 (0.33-0.60) in FTD, and 0.52 (0.48-0.56) in LBD. Among women, these were 0.34 (0.30-0.38), 0.68 (0.39-1.09), and 0.59 (0.51-0.68). CONCLUSIONS: The diagnosis of a neurocognitive disorder does not increase criminal behavior, but rather reduces it by up to 50%. Differences in crime activity are present between different neurocognitive disorders and between the sexes.

Crime, mortality and neurocognitive disorders: A nationwide register study in Finland.

OBJECTIVES: To explore mortality of patients with Alzheimer's disease (AD), frontotemporal dementia (FTD), or Lewy body dementias (LBD) who had criminal behavior in the year preceding diagnosis. METHODS: Data were obtained from the nationwide registers. Mortality was compared between disorder groups with and without criminal acts and with the general population. The cohort included patients who had received a discharge register diagnosis of AD (N = 80,540), FTD (N = 1060), or LBD (N = 10,591) between 1998 and 2015. The incidences of crimes were calculated in the year preceding diagnosis. We further calculated age- and sex-adjusted survivals of different dementia groups with and without criminal acts, and in relation to the general population (SMR, Standardized Mortality Ratio). RESULTS: Criminal behavior was more common in men than in women. It was associated with decreased mortality in the AD group. SMRs due to unnatural causes, and in the LBD and FTD female groups, were higher in patients with criminal behavior than in those without. CONCLUSION: LBD and female FTD patients, who had criminal behavior before diagnosis, were at higher risk of death than patients without such behavior. Novel criminality in older adults may be associated with neurocognitive disorder, in which case medical attention is justified.

Incidence and mortality of alcohol-related dementia and Wernicke-Korsakoff syndrome: A nationwide register study.

BACKGROUND: Epidemiological data on alcohol-related cognitive disorders are scarce. Up-to-date population-based incidence and mortality rates for Wernicke-Korsakoff syndrome (WKS) and alcohol-related dementia (ARD) are necessary to understand the burden of these diseases. METHODS: We collected diagnostic data from the Finnish Hospital Discharge Register and mortality data from Statistics Finland for all persons aged ≥40 years who had received a diagnosis of WKS (n = 1149) or ARD (n = 2432) between 1998 and 2015 in Finland. We calculated the incidences and mortality in relation to the age-, sex- and calendar year-matched general population. Causes of death were ascertained from death certificates. RESULTS: For WKS, the incidence per 100,000 person-years (95% confidence interval (CI)) was 3.7 (3.4-3.9) in men and 1.2 (1.1-1.3) in women. For ARD, the incidence was 8.2 (7.9-8.6) in men and 2.1 (1.9-2.3) in women. The incidence of WKS peaked in people aged 50-59 years and the incidence of ARD in people aged 70-79 years. The standardized mortality ratio (95% CI) was 5.67 (5.25-6.13) in WKS patients and 5.41 (5.14-5.70) in ARD patients. Most of the excess mortality resulted from alcohol-related causes. CONCLUSIONS: To our knowledge, this is the first study describing population-based incidence and mortality rates, sex-segregated data and causes of death in patients with WKS or ARD. Our results establish a point of reference for the incidence of WKS and ARD and show the high mortality and poor prognosis of these disorders.

Criminal Behavior in the Four Years Preceding Diagnosis of Neurocognitive Disorder: A Nationwide Register Study in Finland.

OBJECTIVE: To explore the criminality of patients with subsequent diagnosis of Alzheimer's disease (AD), frontotemporal dementia (FTD), or Lewy body dementias (LBD) in the four years preceding diagnosis. DESIGN: Nationwide register study. SETTING: Data on Finnish patients were collected from the discharge register and data on criminal offending from the police register. Research findings were compared with the same-aged general population. PARTICIPANTS: A total of 92,191 patients who had received a diagnosis of AD (N = 80,540), FTD (N = 1,060), and LBD (N = 10,591) between 1998 and 2015. MEASUREMENTS: Incidences and types of crimes, the standardized criminality ratio (number of actual crimes per number of expected crimes), and the numbers of observed cases and person-years at risk counted in five-year age groups and separately for both genders and yearly. RESULTS: At least one crime was committed by 1.6% of AD women and 12.8% of AD men, with corresponding figures of 5.3% and 23.5% in FTD, and 3.0% and 11.8% in LBD. The first crime was committed on average 2.7 (standard deviation 1.1) years before the diagnosis. The standardized criminality ratio was 1.85 (95% confidence interval [CI] 1.43-2.37) in FTD women and 1.75 (95% CI 1.54-1.98) in FTD men, and in AD 1.11 (95% CI 1.04-1.17) and 1.23 (95% CI 1.20-1.27), respectively. Traffic offences and crimes against property constituted 94% of all offences. CONCLUSION: Criminal acts may occur several years prior to the diagnosis of dementia. If novel criminality occurs later in life, it may be associated with neurocognitive disorder.

Psychiatric hospital admission and long-term care in patients with very-late-onset schizophrenia-like psychosis.

OBJECTIVE: In this register-based study the rates and durations of psychiatric hospitalizations were compared between patients with very-late-onset schizophrenia-like psychosis (VLOSLP, n = 918) and elderly patients with illness onset before 60 years (n = 6142). The proportion of patients ending up in long-term care (LTC) or long-lasting psychiatric hospital care (LLP) was also studied. METHODS: A sample of patients with schizophrenia aged 65 or over was collected from the Finnish Hospital Discharge Register. Psychiatric hospitalizations were calculated per year, and logistic regression was used to compare onset groups and factors associated with ending up in LTC/LLP. RESULTS: Between 1999 and 2003, 27% of patients with VLOSLP and 23% of patients with earlier onset had at least one psychiatric hospitalization (p = 0.020). When the rates of patients' stays in psychiatric hospital per year were compared, the only difference was that in the first year 14% (141/918) and 11% (679/6142) had at least one day in psychiatric hospital (p < 0.001) respectively. In logistic regression onset group of schizophrenia was not associated with LTC/LLP, except weakly the VLOSLP group in women (p = 0.042, OR 1.23). Patients having any cardiovascular disease (p < 0.001, OR 0.63) or a respiratory disease (p = 0.008, OR 0.73) were less likely to end up in LTC/LLP. CONCLUSION: The patients with VLOSLP needed more psychiatric hospital care than those with earlier illness onset. Ending up in LTC/LLP was equally common in both onset groups, but some physical diseases, such as cardiovascular and respiratory, diminished the likelihood of this.

Patients with very-late-onset schizoprhenia-like psychosis have higher mortality rates than elderly patients with earlier onset schizophrenia.

OBJECTIVE: In this register-based study of schizophrenia patients aged 65 years or above, mortality and causes of death diagnosed at age of 60+ (very-late-onset schizophrenia-like psychosis, VLOSLP) were studied in comparison with sex- and age-matched general Finnish population. Standardized Mortality Ratios (SMRs) of VLOSLP patients were also compared with those of earlier onset (below 60 years) schizophrenia patients, and hazard of death was calculated between these patient groups. METHODS: The data was obtained from Finnish nationwide registers and consisted of 918 VLOSLP patients and 6142 earlier onset patients who were at least 65 years on 1 January 1999. The register-based follow-up for mortality covered 10 years between 1999 and 2008. RESULTS: Overall SMR was 5.02 (4.61-5.46) in the group of VLOSLP patients and 2.93 (2.83-3.03) in the group of earlier onset patients. In men, SMRs were 8.31 (7.14-9.62; n = 179) and 2.91 (2.75-3.07, n = 1316) and in women 4.21 (3.78-4.66; n = 364) and 2.94 (2.82-3.07, n = 2055). In the VLOSLP group, SMRs were higher in most causes-of-death categories such as accidents, respiratory diseases, dementias, neoplasms and circulatory diseases. However, in direct comparison adjusted for several variables, the difference between these groups was minimal (Hazard Ratio, HR, 1.16 95%CI 1.05-1.27, p = 0.003). CONCLUSION: Patients with VLOSLP, especially men, are at even higher risk of death than schizophrenia patients with earlier onset. Physical comorbidities and accidents in the VLOSLP group mostly explained this result. Targeted clinical interventions with effective collaboration between psychiatry and primary and specialist-level somatic care are crucial to reduce their excess mortality

Change in antipsychotic usage pattern and risk of relapse in older patients with schizophrenia.

OBJECTIVE: The aim of this study was to explore the use of first (FGAs) and second generation antipsychotics (SGAs) in older outpatients with schizophrenia and schizoaffective disorder. Factors associated with schizophrenic relapses were also studied. METHODS: The study sample consisting of 8792 patients aged 64 years or more was collected from Finnish nationwide registers. The register data on the use of FGAs and SGAs were followed up between 1998 and 2003. Factors associated with psychiatric hospitalization in 1999 indicating relapse were studied using logistic regression analysis. RESULTS: The use of SGAs increased from 2.8% to 12.4%, and the use of FGAs decreased from 57.5% to 39.4%. The use of a combination of SGAs and FGAs increased from 4.0% to 8.5%. The proportion of those who did not buy any antipsychotics varied between 35.8% and 39.7%. The number of patients hospitalized on psychiatric wards within a year (1999; relapsed) was 8.8%. Factors independently associated with relapse were use of combined FGAs and SGAs [odds ratio (OR) 1.70, p = 0.001] and use of antidepressants (OR 1.27, p = 0.019). Diagnosis of cardiovascular disease was negatively associated with risk of schizophrenic relapse (OR 0.84, p = 0.040). CONCLUSION: The use of SGAs increased while the use of FGAs decreased in older outpatients with schizophrenia. Almost 40% of the study sample did not use any antipsychotic medication. The 1-year relapse rate was 8.8%. Several factors, such as combined use of FGAs and SGAs, or antidepressants, were associated with schizophrenic relapse, whereas cardiovascular disease showed a negative association with the relapse.

Mortality and causes of death in older patients with schizophrenia.

OBJECTIVE: The aim of this study was to evaluate mortality and causes of death in older patients with schizophrenia in comparison with the general population. The mortality of patients experiencing relapse was also compared with those in remission. METHODS: The study sample consists of patients (n = 9461) over 65 years by the first of January 1999, with schizophrenia or schizoaffective disorder (ICD-8, ICD-9: 295, ICD-10: F20, F25) as the main register diagnosis during the period 1969-1998. The sample was collected from nationwide registers in Finland and followed up between 1999 and 2008. RESULTS: Overall Standard Mortality Ratio (SMR) of the older schizophrenia patients was 2.69 [95% confidence interval, 2.62-2.76]. For natural causes of death, overall SMR was 2.58 (2.51-2.65; n = 5301), and for unnatural causes of death, it was 11.04 (9.75-12.47; n = 262). The most common causes of death matched those in the general population. Of patients who died during follow-up, 31% (1709/5596) had at least one psychiatric hospitalization within 5 years before follow-up. The SMR for this group was higher (3.92; 3.73-4.11) than in those patients (2.37; 2.29-2.44) with no such treatment during that time. CONCLUSION: All-cause mortality of older patients with schizophrenia was almost threefold that of general population. They died for similar reasons to the general population; however, deaths for unnatural causes were especially common (accidents and suicides). Those patients still experiencing relapses in older age have an increased risk of death compared with those with schizophrenia in remission.

[Severe psychoses in the elderly--schizophrenia and delusional disorder]. / Vanhusten vaikeat psykoosit--skitsofrenia ja harhaluuloisuushäiriö.

The number of persons over 65 years of age with schizophrenia will increase in the future. Geriatric schizophrenia involves bizarre delusions and hallucinations similar to those occurring in younger schizophrenic patients. Delusions of an elderly delusional disorder patient focusing on the family and environment easily lead to social withdrawal. Persons becoming ill with initial psychosis at an older age should be subjected to thorough diagnostic examinations. Organic brain diseases constitute the major differential diagnostic illnesses. Second generation antipsychotics are the first-line drugs in the treatment of geriatric schizophrenia and delusional disorder. The patients benefit from a regular therapeutic contact and treatment of associated diseases.