The use of network pharmacology and blood metabolomics to study the pathogenesis of violent aggression in patients with schizophrenia and the related drug mechanisms of action provides new directions for reducing the risk of violent aggression and optimizing treatment plans.

To explore the metabolic regulatory mechanism of olanzapine in treating patients with schizophrenia with a moderate to high risk of violent aggression.

Metabolomic technology was used to screen differentially abundant metabolites in patients with schizophrenia with a moderate to high risk of violent aggression before and after olanzapine treatment, and the related metabolic pathways were identified. Network pharmacology was used to establish protein-protein interaction networks of the core targets of olanzapine. Gene Ontology functional analysis and Kyoto Encyclopedia of Genes and Genomes pathway enrichment analysis were subsequently performed.

Compared with the healthy group, the patients with schizophrenia group presented significant changes in the levels of 24 metabolites related to the disruption of 9 metabolic pathways, among which the key pathways were the alanine, aspartate and glutamate metabolism and arginine biosynthesis pathways. After treatment with olanzapine, the levels of 10 differentially abundant metabolites were significantly reversed in patients with schizophrenia. Olanzapine effectively regulated six metabolic pathways, among which the key pathways were alanine, aspartate and glutamate metabolism and arginine biosynthesis pathways. Ten core targets of olanzapine were involved in several key pathways.

The metabolic pathways of alanine, aspartate, and glutamate metabolism and arginine biosynthesis are the key pathways involved in olanzapine treatment for aggressive schizophrenia.

The relationship between schizophrenia and violence is heterogeneous and complex. The aim of this study was to explore the characteristics and the potential risk factors for violence crime in patients with schizophrenia.

We conducted a retrospective case-control study at the Judicial Psychiatric Identification Unit of Xiangya Second Hospital of Central South University from January 1, 2013 to December 31, 2016. The case group included violent offenders diagnosed with schizophrenia, while the control group comprised non-violent individuals with the same diagnosis.

There were 308 individuals in the violent group [subdivided into the homicide group (n = 155) and the intentional injury group (n = 153)] and 139 individuals in the non-violent group. A risk model showed that a history of violence (odds ratio (OR) = 2.88, 95% CI [1.79-4.64]), persecutory delusions (OR = 2.57, 95% CI [1.63-4.06]), regular treatment in the previous four weeks (OR = 0.29, 95% CI [0.16-0.51]) and insight (OR = 0.30, 95% CI [0.14-0.62]) were independently associated with violence.

This study provided useful clinical information to identify risk factors for violence and develop better strategic programs to manage violence in patients with schizophrenia.

Aggression and violence are common day to day problems in psychiatric settings. However, the optimal means of assessing that risk remains unclear. In the context of that uncertainty many tools have evolved, among which the HCR-20 is one of the most globally accepted, though many questions remain about its performance, how and when it should be deployed and how it can be most effectively used. In this 12 month follow up study of 210 forensic psychiatric inpatients with a diagnosis of a schizophrenia spectrum disorder we explored these issues. We found that the performance of the HCR-20v3, especially its Total score, performed well up to 6 months after it was rated but its performance deteriorated after that. Repeating the HCR-20v3 at 6 months stabilised the risk assessment and led to improved performance in the second months over and above the first rating. The HCR-20v3 was good at identifying those subjects at low risk of violence over 6 months of follow up in a forensic inpatient setting. The real-world implications of this study are that the HCR-20v3 is an effective means of identifying patient at low risk of violence, but it should be reassessed every 6 months.

The risk of violence is higher in schizophrenia spectrum disorders (SSD) compared to the general population and it is a pressing and understudied issue. Several dispositional and environmental factors have been previously correlated with violence, however, there has been little success in assessing their ability to predict violence patterns across the life span. This study aims to assess violence prediction based on personality traits, psychological resilience, and life-course adversities in a non-forensic population of SSD patients. In a sample of 231 patients with SSD, we assessed violence using the Brown-Goodwin History of Lifetime Aggression Scale and conducted cross-sectional assessments of possible predictors such as childhood trauma, personality traits and resilience scores. We then utilized a logistic regression classification algorithm to predict different violence trajectories based on the proposed risk factors. Our model significantly predicted individuals with violence in both childhood and adulthood, as well as childhood-only violence (p < 0.001). However, the model did not show significance for adult-only violence (p = 0.604). In all given trajectories, female sex appeared to be protective against violence, while stressful life events appeared to contribute to it. These results suggest that distinct factors can better inform risk assessment of lifespan violence patterns for personalized interventions in SSD.

Violent behavior carried out by patients with schizophrenia (SCZ) is a public health issue of increasing importance that may involve inflammation. Peripheral inflammatory biomarkers, such as the systemic immune inflammation index (SII), the neutrophil lymphocyte ratio (NLR), the platelet-lymphocyte ratio (PLR) and the monocyte lymphocyte ratio (MLR) are objective, easily accessible and cost-effective measures of inflammation. However, there are sparse studies investigating the role of peripheral inflammatory biomarkers in violence of patients with SCZ.

160 inpatients diagnosed with SCZ between January and December 2022 were recruited into this study. Violent behavior and positive symptoms of all participants were evaluated using Modified Overt Aggression Scale (MOAS) and Positive and Negative Syndrome Scale (PANSS), respectively. The partial correlation analysis was performed to examine the relationship of inflammatory indices and positive symptoms. Based on machine learning (ML) algorithms, these different inflammatory indices between groups were used to develop predictive models for violence in SCZ patients.

After controlling for age, SII, NLR, MLR and PANSS positive scores were found to be increased in SCZ patients with violence, compared to patients without violence. SII, NLR and MLR were positively related to positive symptoms in all participants. Positive symptoms partially mediated the effects of peripheral inflammatory indices on violent behavior in SCZ. Among seven ML algorithms, penalized discriminant analysis (pda) had the best performance, with its an area under the receiver operator characteristic curve (AUC) being 0.7082. Subsequently, with the use of pda, we developed predictive models using four inflammatory indices, respectively. SII had the best performance and its AUC was 0.6613.

These findings suggest that inflammation is involved in violent behavior of SCZ patients and positive symptoms partially mediate this association. The models built by peripheral inflammatory indices have a good median performance in predicting violent behavior in SCZ patients.

Psychiatric symptoms are common risk factors of violent behaviors among psychiatric patients. This study explored the interrelationship between violence and psychiatric symptoms in male psychiatric inpatients. This is a cross-sectional survey conducted in 2019. All patients admitted to the Male Psychiatry Unit of the Second Xiangya Hospital were consecutively recruited. The presence of five violent behaviors and eleven psychiatric symptoms were collected by reviewing medical records and were included as categorical variable in the network analyses. A total of 673 participants were included. The most central symptoms were "flight of ideas", "property-oriented violence", "emotional high", "verbal violence", "physical violence attempt", and "physical violence" in the network of psychiatric symptoms and violent behaviors. The bridge symptoms connecting violence and psychiatric symptoms were "verbal violence", "property-oriented violence", "hyperbulia", and "emotional high" according to the indices of bridge expected influence. The directed acyclic graph analysis revealed that "emotional high" and "hyperbulia" were the key psychiatric symptoms triggering violence, while "verbal violence" and "property-oriented violence" were the most upstream violent behavior. Verbal and property-oriented violence should be addressed in the risk assessment among male psychiatric inpatients. In addition, emotional high and hyperbulia are the potential treatment targets for violent behaviors.

Public stigma and fear are heightened in cases of extreme violence perpetrated by persons with serious mental illness (SMI). Prevention efforts require understanding of illness patterns and treatment needs prior to these events unfolding.

To examine mental health service utilisation by persons who committed homicide and entered into forensic care, to investigate the adequacy of mental healthcare preceding these offences.

Forensic patients across two mental health hospitals in Ontario with an admitting offence of homicide between 2011 and 2021 were identified (n = 112). Sociodemographic, clinical and offence-related variables were coded from the health record and reports prepared for the forensic tribunal.

Most patients (75.7%) had mental health contacts preceding the homicide, with 28.4% having a psychiatric in-patient admission in the year prior. For those with service contacts in the year preceding, 50.9% had had only sporadic contact and 70.7% were non-adherent with prescribed medications. Victims were commonly known to the individual (35.7%) and were often family members in care-providing roles (55.4%). Examination of age at onset of illness and offending patterns suggested that most persons admitted to forensic care for homicide act in the context of illness and exhibit a low frequency of pre-homicide offending.

Many individuals admitted to forensic care for homicide have had inadequate mental healthcare leading up to this point. Effective responses to reduce and manage risk should encompass services that proactively address illness-related (e.g. earlier access and better maintenance in care) and criminogenic (e.g. substance use treatment, employment and psychosocial supports) domains.

There has been a substantial change in the law on the provision of secure health services for offender-patients in Italy, a country currently with the lowest general psychiatry bed availability per head of the population in Europe, raising questions about possible differences in offender-patient admissions between European countries.

In this multicentre case-control study, our aim was to compare the socio-demographic, clinical and criminological characteristics of a sample of Italian forensic in-patients with schizophrenia or similar psychosis with patients in a similar diagnostic range in specialist in-patient services elsewhere in Europe.

Secure hospital unit in-patients with psychosis were recruited across five European countries (Italy, Austria, Germany, Poland and England). Consenting patients were interviewed by researchers and assessed using a multidimensional standardised process. Within country similarities between Austria, Germany, Poland and England were confirmed.

Overall, 39 Italian participants had had fewer years of education than the 182 patients in the other countries and were less likely to have ever had skilled or professional employment. The Italian patients had been older at first contact with any mental health services than the other Europeans. Diagnosed comorbidity rates were similar, but the Italian group reported higher levels of disability. Although the other European forensic patients were more likely to be undergoing treatment at the time of their index offence, they were also more likely to have been poorly compliant with treatment. The rate of suicide-related behaviours was significantly lower among the Italian patients than among the others.

Notwithstanding similar diagnoses, important differences emerged between patients in Italian forensic mental health resident services and those in four other European countries, some possibly reflecting less access to earlier relevant services in Italy. Others, including lower disability ratings among the Italian patients and a lower rate of suicide-related behaviours, may indicate that the Italian reforms carry benefits. This is worthy of further evaluation.

Paranoia is a common and impairing psychosis symptom, which exists along a severity continuum that extends into the general population. Individuals at clinical high-risk for psychosis (CHR) frequently experience paranoia and this may elevate their risk for developing full psychosis. Nonetheless, limited work has examined the efficient measurement of paranoia in CHR individuals. The present study aimed to validate an often-used self-report measure, the revised green paranoid thoughts scale (RGPTS), in this critical population.

Participants were CHR individuals (n = 103), mixed clinical controls (n = 80), and healthy controls (n = 71) who completed self-report and interview measures. Confirmatory factor analysis (CFA), psychometric indices, group differences, and relations to external measures were used to evaluate the reliability and validity of the RGPTS.

CFA replicated a two-factor structure for the RGPTS and the associated reference and persecution scales were reliable. CHR individuals scored significantly higher on both reference and persecution, relative to both healthy (ds = 1.03, 0.86) and clinical controls (ds = 0.64, 0.73). In CHR participants, correlations between reference and persecution and external measures were smaller than expected, though showed evidence of discriminant validity (e.g., interviewer-rated paranoia, r = 0.24). When examined in the full sample, correlation magnitude was larger and follow-up analyses indicated that reference related most specifically to paranoia (β = 0.32), whereas persecution uniquely related to poor social functioning (β = -0.29).

These results demonstrate the reliability and validity of the RGPTS, though its scales related more weakly to severity in CHR individuals. The RGPTS may be useful in future work aiming to develop symptom-specific models of emerging paranoia in CHR individuals.

A growing body of literature demonstrates strong association between poor mental health and criminal recidivism, but research from county jails is limited.

Our aim was to examine the relationship between re-arrest and severe mental illnesses-schizophrenia, bipolar disorder and major depressive disorder-together and separately and with substance use disorders, separately and as comorbid conditions, in a mid-sized county jail cohort in the southeastern United States.

We examined the full cohort of 8097 individuals who were booked into the County Detention Facility between 31 January 2014 and 31 January 2015. Their incarceration data were merged with data from the local health system to investigate the presence of severe mental illness and substance use disorder diagnoses. Re-arrest data were tracked for 4 years after the index arrest.

Approximately 60% of the cohort was re-arrested within 4 years. People with substance use disorders, with or without severe mental illness, had higher re-arrest rates than those with severe mental illness alone or neither diagnosis. Drug-associated arrests did not explain this finding.

Using detailed mental illness diagnosis data with a complete cohort of detained arrestees, we have shown the wide range of need among such individuals. By demonstrating that drug-associated crimes per se do not drive repeated arrest, we underscore a need to examine other factors that promote the cycle of repeated arrest in this population. Each individual requires treatment tailored to their personal psychiatric and criminogenic needs.

The prediction and prevention of aggression in individuals with schizophrenia remains a top priority within forensic psychiatric settings. While risk assessment methods are well rooted in forensic psychiatry, there are no available tools to predict longitudinal physical aggression in patients with schizophrenia within forensic settings at an individual level. In the present study, we used evidence-based risk and protective factors, as well as variables related to course of treatment assessed at baseline, to predict prospective incidents of physical aggression (4-month, 12-month, and 18-month follow-up) among 151 patients with schizophrenia within the forensic mental healthcare system. Across our HARM models, the balanced accuracy (sensitivity + specificity/2) of predicting physical aggressive incidents in patients with schizophrenia ranged from 59.73 to 87.33% at 4-month follow-up, 68.31-80.10% at 12-month follow-up, and 46.22-81.63% at 18-month follow-up, respectively. Additionally, we developed separate models, using clinician rated clinical judgement of short term and immediate violent risk, as a measure of comparison. Several modifiable evidence-based predictors of prospective physical aggression in schizophrenia were identified, including impulse control, substance abuse, impulsivity, treatment non-adherence, mood and psychotic symptoms, substance abuse, and poor family support. To the best of our knowledge, our HARM models are the first to predict longitudinal physical aggression at an individual level in patients with schizophrenia in forensic settings. However, it is important to caution that since these machine learning models were developed in the context of forensic settings, they may not be generalisable to individuals with schizophrenia more broadly. Moreover, a low base rate of physical aggression was observed in the testing set (6.0-11.6% across timepoints). As such, larger cohorts will be required to determine the replicability of these findings.

The role of serious mental illness among those who sexually offend is not well understood. We investigated clinical and risk-related areas of difference between male forensic psychiatric patients with (n = 86) and without (n = 245) a sexual offense history, including the age at which indications of mental disorder and criminal offending first emerged, from a registry of Ontario patients adjudicated Not Criminally Responsible on account of Mental Disorder (NCRMD) from 1999-2012. We further explored motivations for offending among a subset of patients deemed NCRMD for a sexual offense specifically (n = 41). While no differences were found in the age onset of illness or offending across those with and without a sexual offending history, the former group was rated as having higher levels of historical/static risk for violence. Forensic patients with a sexual offense history were also more likely to offend against a stranger, and less likely to offend against a family member. Sexual index offenses were psychotically-motivated in the majority of cases, but with a meaningful proportion appearing to reflect criminogenic motivations, especially substance use and paraphilic interests. Results suggest greater similarity than difference among forensic patients with and without a sexual offense history, but also highlight an important divergence from the literature showing that victims of sexual offenses are frequently known to the individual committing them.

Though controversial for its various disadvantages, involuntary admission (IA) is necessary in providing mental health care for patients suffering from schizophrenia in China. This article examines the IA rate in a representative sample, and under which circumstances are these patients more likely to be admitted involuntarily.

Adult patients consecutively admitted to two typical hospitals in Shanghai between 2013 and 2014 with a diagnosis of ICD-10 schizophrenia were included. 2167 patients were included in this study. Sociodemographic and clinical data, as well as personal information of psychiatrists who made risk assessment, were collected. The whole sample was divided into voluntary and involuntary admission groups. Group comparisons were performed with SPSS 17.0, using one-way ANOVA, Wilcoxon rank sum test, Chi-squares and Logistic regression.

Among 2167 inpatients, the majority (2003, 92.4%) were involuntarily admitted. Clinical features, including age of patients (p < 0.001, OR = 1.037), lacking of insight (p < 0.001, OR = 3.691), were statistically significant for IA. Psychiatrist's age (p < 0.001, OR = 1.042) was independently associated with IA. However, risk behaviors had dramatically affected patients' admission status, of which the strongest predictor of IA was noncompliance with treatment (p < 0.001, OR = 3.597). The areas under the curve of the ROC and accuracy for the regression model were 0.815 and 0.927, respectively.

IA patients account for a major proportion of all those hospitalized with schizophrenia in China. Insights and risk behaviors contributed the most reasons for admission status of patients. This research shed light on necessity of further qualitative studies learning detailed evaluation processes of IA and high-quality interventional studies aiming to limit the performance of IA among patients with schizophrenia.

To identify individual and clinical risk factors of aggressiveness, including exposure to different forms of childhood trauma, in a sample of Lebanese patients with schizophrenia.

A total of 131 patients diagnosed with schizophrenia participated in this cross-sectional study.

Higher physical (Beta = 0.24, p < 0.001) and sexual (Beta = 0.29, p = 0.003) abuse, alcohol drinking (Beta = 1.46, p = 0.008), having a history of head trauma (Beta = 1.10, p = 0.041), and male gender (Beta = -1.59, p = 0.009) were significantly associated with higher mean aggression scores.

Our investigation of the factors linked to aggressiveness in patients with schizophrenia complement those of earlier findings, showing that the relationship between interacting individual and environmental risk factors and later aggressiveness is quite complex, and needs further longitudinal and prospective studies.

Among forensic patients with schizophrenia spectrum disorders, the association between symptomatology and violence is still not entirely clear in literature, especially because symptoms shift both during the acute phase of the illness and after. The aims were to investigate the level of symptomatology in forensic patients and to evaluate if there are differences in the level of symptoms between forensic and non-forensic patients. According to PRISMA guidelines, a systematic search was performed in PubMed, Web of Science, and ProQuest, using the following key words: "forensic" AND "Positive and Negative Syndrome Scale" OR "PANSS". A total of 27 studies were included in the systematic review, while only 23 studies in the meta-analysis. The overall sample included a total of 1702 participants, most commonly male and inpatients in forensic settings. We found that studies with an entirely male sample had significantly lower Positive PANSS ratings than studies with mixed samples. Although both forensic and non-forensic patients were affected by mild psychopathological symptoms, forensic patients presented higher ratings in all four PANSS scales. This meta-analysis shows that forensic patients reported a mild level of symptomatology, as assessed with the PANSS, and therefore might be considered as patients in partial remission. Among patients with schizophrenia, the association between symptoms and violence is very complex: many factors might be considered as key mediators and thus should be taken into account to explain this association. Further studies are needed.Trial registration all materials and data can be found on the OSF framework: https://osf.io/5ceja (date of registration: 8 September 2021).

Olanzapine pamoate has been shown to be an effective second-generation long-acting injection. Its popularity has possibly been adversely affected by the rare incidence of post-injection syndrome (PIS) and the associated requirement to monitor for 3 h after each injection.

This study aimed to collect and present data on the use of olanzapine long-acting injection (OLAI) over a 10-year period in a high-security forensic hospital in South East England.

This was a non-interventional retrospective study collecting information from anonymised electronic patient and prescription records. As per hospital Trust guidelines, patient consent to access of hospital records was presumed unless explicitly withdrawn.

All patients prescribed OLAI between the years 2009 and 2019 were identified. Data collected included date that OLAI was started, stopped, dose range, side effects and concomitant medication.

Of 88 patients who were started OLAI, 45 (51%) continued at month 24. At 60 months, 22 of 70 (31%) patients for whom data were available continued with OLAI. Over 60% of continuers were on higher than recommended doses. Of almost 5000 injections administered, there was 1 episode of PIS.

OLAI is an effective treatment for schizophrenia and schizoaffective disorder, especially when used in patients have been able to tolerate the drug and were stabilised on it for 24 months. In over half the patients who continued OLAI, the doses were higher than that recommended by the manufacturer. The incidence of PIS in this study was very low in comparison with other studies.

2049.

The purpose of this descriptive study was to investigate overkill in a representative sample of Greek psychiatric patients found not guilty by reason of insanity (NGRIs) from a forensic psychiatric - criminological standpoint and explore possible correlations of the phenomenon with socio-cultural or psychiatric factors. Overall, 24 forensic psychiatric records of overkill offenders were identified throughout the 5-year records of the national forensic psychiatric service in northern Greek mainland. The pattern that has emerged from the statistical results of the present study on the victims of overkill within the Greek borders was generally in line with global literature on homicide perpetrators. The mean age of overkill offenders (at the time of enactment of the crime) was estimated at 36.3 years ranging from 19 to 55 years (variance = 146.72; standard deviation = 12.11). The number of male single-offence killers was ten-times larger compared to their female counterparts, while the number of male multiple-offence killers were three-times larger compared to their female counterparts. Male offenders were averagely 15 years younger (mean 33.7; variance = 81.69; standard deviation = 9) in comparison to female offenders, and single-offence killers were averagely ten years younger compared to multiple-offence killers (mean 40.2; variance = 185.19; standard deviation = 13.6). The phenomenon correlated more strongly with homicides in the context of schizophrenia spectrum disorders (80-100%) as well as domestic violence. Overall, males outnumbered females both as offenders (approximately five-times) and victims (approximately three-times), but regarding domestic violence, the sad majority of overkill victims stood for females murdered by their male relatives. Close female relatives (especially mothers and grandmothers) were most often victimized. Female-perpetrated overkill was directed against male individuals with whom offenders shared a relationship (intimate partners and minors). An important finding was the fact that three-quarters of the overall perpetrator sample were under prescribed medication at the time of offence, but with a very low compliance rate (5.6%). This last particular finding of the present study demonstrated that mental health services within community in Greece may unfortunately have been ineffective in addressing issues requiring risk assessment and timely intervention.

Solitary confinement is still used in prisons in the USA, despite its links to poor health. Past research suggests that there may be disparities by race, ethnicity, sex and mental disorders regarding who is placed in solitary confinement, although nationwide studies have been sparse.

To explore possible disparities by race, ethnicity, sex, sexual orientation, adverse childhood experiences and mental disorders in solitary confinement as a disciplinary action for adults incarcerated in USA prisons.

Data come from a recently released national survey of 24,848 adults incarcerated in the USA-the 2016 Survey of Prison Inmates. Logistic regression models were used to identify disparities in the use of disciplinary action and solitary confinement as a disciplinary action, while controlling for type of rule violation.

After controlling for rule violation type, solitary confinement was used as a disciplinary action at higher rates for people who: were multiracial, as compared to white (aOR = 1.30), male, as compared to female (aOR = 1.46), bisexual, as compared to heterosexual (aOR = 1.64), had multiple mental disorders, as compared to none (aOR = 1.22) or had more adverse childhood experiences (aOR = 1.13).

Findings highlight demographic and health disparities in the use of solitary confinement, which may further widen health disparities. More effective implementation of policies to reduce the use of solitary confinement are still needed. Mental health professionals should have an active role in advising on measures when mental disorder is a factor and must ensure adequate treatment of disorders in prison or transfer to health facilities.

Schizophrenia is one of the most common severe mental disorders associated with an increased risk of violence. The present study compares the demographical, clinical, and criminological characteristics of the patients with schizophrenia who committed different types of violence to relatives, acquaintances, or strangers.

Archives of the violent offenders with schizophrenia referred to forensic psychiatric assessments from January 2015 to December 2019 in the West China Forensic Medicine Assessment Center in China were analyzed. The demographic information, mental illness history, and criminological characteristics of the offenders were collected. The clinical symptoms, previous violent behaviors, and social deficits were also evaluated. One-way ANOVA, Kruskal-Wallis test, Chi-square test, and logistic regression analysis were enrolled to do the statistical analysis.

The study enrolled 332 cases: 165 cases (49.7%) in the acquaintance victim group (AV), 96 cases (28.9%) in the relative victim group (RV), and 71 cases (21.4%) in the stranger victim group (SV). The multinomial logistic regression analysis revealed that older patients were less likely to attack relatives (OR = 0.966, 95% CI = 0.944-0.990; p = 0.005), and strangers, (OR = 0.971, 95% CI = 0.944-0.998; p = 0.034). Patients who lived with others were more inclined to attack relatives (OR = 15.057, 95% CI = 3.508-64.628; p < 0.001). Additionally, employed patients were more likely to attack strangers (OR = 2.034, 95% CI = 1.036-3.994; p = 0.039). The regression equation did not include psychiatric symptoms. For RV and AV victims, the risk of death was higher compared to that of SV victims (OR = 13.778, p < 0.001; OR = 2.663, p = 0.014).

In the interpersonal violence cases committed by schizophrenia patients, the victim type correlates with demographic characteristics of offenders such as living situation, age, and employment status, but not with the psychiatric symptoms. The majority of victims were acquaintances and relatives, and the relative victims having more severe injuries. In order to decrease interpersonal violence, especially violent crimes, more people, especially family members and neighbors, should be educated about symptoms of schizophrenia, the ways to communicate with the patients, and the methods for crisis management.

Recent literature examining associations between cognitive function, clinical features, and violence in patients with schizophrenia has been growing; however, the results are inconsistent. Reports on social function and personality are limited. These studies are yet to be reflected in risk assessment tools and management plans. The aim of this study is to provide a resource for risk assessment and intervention studies by conducting multifaceted well-established assessments in a large population. Data from 355 patients with schizophrenia (112 patients with a history of violence; 243 patients without a history of violence) and 1265 healthy subjects were extracted from a large database of individuals with mental disorders in a general psychiatric population in Japan. The associations between violence in patients with schizophrenia and intellectual function, cognitive function (memory function, executive function, attentional function, verbal learning, processing speed, social cognition), clinical variables, personality traits, social function, and quality of life (QOL) were analyzed. Compared with healthy subjects, the schizophrenia group had broadly impaired cognitive function and social cognition, and their personality traits showed similar differences as those reported previously. Patients with schizophrenia with a history of violence showed significantly more impaired visual memory function (P = 1.9 × 10^-5, Cohen's d = 0.34), longer hospitalization (P = 5.9 × 10^-4, Cohen's d = 0.38), more severe excited factor on Positive and Negative Syndrome Scale (P = 1.6 × 10^-4, Cohen's d = 0.47), higher self-transcendence personality construct on the Temperament and Character Inventory (P = 1.8 × 10^-4, Cohen's d = 0.46), and shorter total working hours per week (P = 4.8 × 10^-4, Cohen's d = 0.53) than those with schizophrenia without a history of violence. New findings, including impaired visual memory, a high self-transcendence personality trait, and shorter total working hours, could be focused on in future interventional research.

Preventing the relapse of a psychotic episode is a challenge for the treatment of schizophrenia. Patients with schizophrenia suffer from a few to a dozen relapses in their lifetime. The use of long-acting injectable (LAI) antipsychotics in the treatment of schizophrenia is associated with less frequent recurrences of psychotic symptoms, better compliance, and better quality of life. The aim of the report is to present the findings of the successful management of treatment-resistant schizophrenia in a patient with persistent non-compliance using a combination of typical and atypical LAI antipsychotics. Since there was a history of non-adherence (irregular controls in outpatient clinics) by the patient, clozapine was not considered a therapeutic option. At the start of the treatment, olanzapine LAI was administered to the patient at a dosage of 300 mg fortnightly because of the good response and tolerance reported in the previous treatment. The treatment was continued for several weeks, and because of the persistence of constant delusions, labile affect, and aggressive behavioral tendencies, a second antipsychotic, zuclopenthyxole, was added, which was initially administered orally. After 4 weeks of combined treatment, the patient's mental state improved. There was no report of delusions, and his mood was much more stable. Zuclopenthyxole was switched to the LAI antipsychotic form due to the patient's history of persistent non-compliance, lack of insight into the disease, and the risk of aggressiveness toward others. Then, 200 mg of zuclopenthyxole decanoate was administered fortnightly. The patient was discharged from the hospital without any symptoms of delusions or hallucinations. The patient's clinical state presented negative symptoms, of which avolition and diminished social activity were dominant. The patient tolerated the treatment well, and sedation and extrapyramidal symptoms were not observed. The patient continued the injections alternately (one injection per week) to obtain regular visits to the outpatient clinic.

Schizophrenia patients with violent behavior are a severe public health concern, but the correlates of this violent behavior are unknown. Additionally, the relationship between neurocognitive function and violent behavior in Chinese patients with schizophrenia has not yet been investigated.

A total of 337 schizophrenia inpatients were recruited. The Positive and Negative Syndrome Scale (PANSS) was used to assess psychopathological symptoms. Neurocognitive functioning was evaluated using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS).

The percentage of violent behavior was 10.4% in patients with schizophrenia. Patients with violent behavior had higher PANSS-positive, excited, and total subscale scores than patients who did not show violent behavior. Patients with violent behavior also had lower RBANS language, semantic fluency, and total subscale scores. Gender (OR = 0.066∼0.819, p = 0.023), illness duration (OR = 0.876∼0.971, p = 0.002), smoking (OR = 1.127∼2.950, p = 0.014), the PANSS positive subscale (OR = 1.050∼1.197, p = 0.001), and the RBANS language subscale (OR = 0.927∼0.987, p = 0.005) significantly contributed to the development of violent behavior in schizophrenia patients.

Our findings revealed that cognitive and clinical assessments should be considered in comprehensive assessments of future risks of violence in schizophrenia patients.

Some persons developing, or presenting, schizophrenia engage in aggressive behaviour (AB) and/or criminal offending. Most of these individuals display AB prior to a first episode of psychosis (FEP). In fact, approximately one-third of FEP patients have a history of AB, some additionally display other antisocial behaviours (A+AB). The large majority of these individuals have presented conduct problems since childhood, benefit from clozapine, have extensive treatment needs, and are unlikely to comply with treatment. A smaller sub-group begin to engage in AB as illness onsets. A+AB persists, often for many years in spite of treatment-as-usual, until a victim is seriously harmed. This article proposes providing multi-component treatment programs at FEP in order to prevent aggressive and antisocial behaviours of persons with schizophrenia.

Non-systematic reviews of epidemiological studies of AB among persons with schizophrenia, of the defining characteristics of sub-types of persons with schizophrenia who engage in AB and their responses to treatment, and of FEP service outcomes.

Studies have shown that mental health services that simultaneously target schizophrenia and aggressive behaviour are most effective both in reducing psychotic symptoms and aggressive behaviour. Evidence, although not abundant, suggests that a multi-component treatment program that would include the components recommended to treat schizophrenia and cognitive-behavioural interventions to reduce A+AB, and the other factors promoting A+AB such as substance misuse, victimisation, and poor recognition of emotions in the faces of others has the potential to effectively treat schizophrenia and reduce A+AB. Patients with a recent onset of AB would require few components of treatment, while those with prior conduct disorder would require all. Such a program of treatment would be long and intense.

Trials are needed to test the effectiveness of multi-component treatment programs targeting schizophrenia and A+AB at FEP. Studies are also necessary to determine whether providing such programs in hospitals and/or prisons, with long-term community after-care, and in some cases with court orders to participate in treatment, would enhance effectiveness. Whether investing at FEP would be cost-effective requires investigation.

Despite numerous risk factors associated with violence in patients with schizophrenia, predicting and preventing violent behavior is still a challenge. At present, machine learning (ML) has become a promising strategy for guiding individualized assessment. To build an effective model to predict the risk of violence in patients with schizophrenia, we proposed a hybrid ML method to improve the prediction capability in 42 violent offenders with schizophrenia and 33 non-violent patients with schizophrenia. The results revealed that the final model, which combined multimodal data, achieved the highest prediction performance with an accuracy of 90.67%. Specifically, the model, which fused three modalities of neuroimaging data, achieved a better accuracy than other fused models. In addition, the msot discriminative neuroimaging features involved in the prefrontal-temporal cognitive circuit and striatum reward system, indicating that dysfunction in cortical-subcortical circuits might be associated with high risk of violence in patients with schizophrenia. This study provides the first evidence supporting that the combination of specific multimodal neuroimaging and clinical data in ML analysis can effectively identify violent patients with schizophrenia. Furthermore, this work is crucial for the development of neuro-prediction models that could facilitate individualized treatment and interventions for violent behaviors in patients with schizophrenia.

Schizophrenia is a severe psychiatric disorder. Poor medical adherence increases relapse rate. Long-acting injection of antipsychotic agent is developed for improving medical adherence. In this study, we examined the effect of paliperidone long-acting injection (PLAI) treatment in patients with schizophrenia in a real-world setting.

In this retrospective cohort study, 467 patients with schizophrenia were enrolled, treated with risperidone PLAI or oral antipsychotics, and followed for 1 year. Concomitant medication, namely anticonvulsants, antidepressants, anxiolytics, sedatives or hypnotics, anticholinergics, and beta-blockers, were administered. Patients were classified into 2 groups: the LAI group (patients received LAI for treatment) and the NLAI group (patients taking only oral antipsychotics). The incidence of hospitalization, the length of hospitalization, and the incidence of emergency room visits were assessed.

The LAI group had a higher incidence of psychiatric acute ward admission (NLAI group = 4.8%; LAI = 30.3%) and emergency room visits (NLAI group = 7.3%; LAI group = 36.0%) before enrolment. During the one-year follow-up, the incidence of acute ward admission and emergency room visit did not differ in the NLAI group (P = .586 and .241) compared with before enrolment, whereas both incidences were significantly decreased in the LAI group (P < .0001 in both of them).

PLAI reduces the incidence of admission and emergency room visits.

The prevalence of severe mental illness (SMI) in correctional settings is alarmingly high. Some correctional facilities have developed mental health units (MHUs) to treat incarcerated individuals with SMI.

To identify existing MHUs in the United States and collate information on these units.

A systematic review using Criminal Justice Abstracts, ERIC, PsycINFO, PubMed, and SocINDEX, plus an exploratory review using the Google search engine were conducted. MHUs were included if they were located within an adult correctional facility in the United States, specifically catered to SMI populations, and were in active operation as of June 2019.

Eleven articles were identified through the peer-reviewed literature, but there were still major gaps in the information on MHUs. The Google search identified 317 MHUs. The majority of units were located within prisons (79.5%) and served only men (76%). The Google search found information indicating that 169 (53.3%) offered groups or programming to inmates; 104 (32.8%) offered individual therapy; and 89 (23%) offered both. One hundred sixty-six units (52.4%) had dedicated mental health staff, and 75 (23.7%) provided mental health training to correctional officers. Information on funding and outcomes of the MHUs is presented.

Use of the Google search engine and sources that have not been peer reviewed limits the robustness of conclusions about the MHUs.

Standards for developing and implementing MHUs are not widespread. The shortcomings of current MHUs are discussed in the context of desired criteria for size, staffing, and programming.

Developmental trajectories regarding the age onset of violence and offending have not routinely considered the role of major mental illness (MMI). In parallel, despite several studies investigating the relationship between MMI, violence and offending, fewer have identified motivational processes that may link illness to these outcomes in a more direct and proximal manner. This study investigates whether subtypes of forensic psychiatric patients deemed Not Criminally Responsible on account of Mental Disorder (N = 91) can be identified based on the age onset of mental illness and offending behavior, and whether information on motivational influences for offending-elicited both from the patient directly and detailed collateral information-contributes to the clinical utility of this typology. Results indicated that most patients reported engaging in violence (51%) or antisocial behaviors (72%) prior to the onset of MMI, but that the index offense(s) resulting in forensic admission were predominantly psychotically motivated. In contrast to patients for whom the onset of MMI occurred prior to offending, patients exhibiting premorbid violence had higher levels of risk and criminogenic need; they were more likely to be diagnosed with personality and substance use disorders, and to have conventional (i.e., non-illness-related) motivations ascribed to their index offense. Findings are consistent with the existing literature regarding subgroups of mentally disordered offenders, but provide new information regarding proximal risk factors for violence through better identification of motivational processes.

The reduction of misconduct levels and its prevention are two important objectives in prison settings, for which several strategies and control mechanisms are implemented.

We explore the relationship between a set of socio-demographic, judicial, affective, and personality characteristics and various expressions of aggression.

An Ecuadorian sample of 675 sentenced male prisoners was assessed using the Spanish adaptation of the Personality Assessment Inventory (PAI). Three subscales of the PAI were used as outcome measures: Aggressive Attitude (AGG-A), Verbal Aggression (AGG-V), and Physical Aggression (AGG-P).

Using path analysis, three models were obtained, each of which had four indicators. Borderline personality features and antisocial personality features emerged as indicators that were common to the three models. Anxiety-related disorders and non-support were indicators specific to AGG-A, whilst schizophrenia and non-support were indicators of AGG-V, and drug problems and crimes against property were indicators of AGG-P.

This study indicates that each expression of aggression has a different structure, which suggests its usefulness for detecting the tendency of an inmate to predominantly express one form of aggression or another.

The attribution of criminal responsibility in the context of substance intoxication is a matter of controversy in forensic psychiatry. In 2011, the Supreme Court of Canada ruled that Tommy Bouchard-Lebrun was guilty in the straightforward case of a crime committed while in a state of substance-induced psychosis by an individual without a history of mental disorder. However, the ruling may since have served as a precedent also for settling cases where an offence is committed while in a certain state of intoxication and where there is much more diagnostic uncertainty. The goal of our research was to study the impact of the Bouchard-Lebrun Supreme Court decision on rates of criminal responsibility judgements and toxic psychosis diagnosis in the context of such cases. Applying a time-trend ecological study design, we conducted a chart review of every patient treated at the forensic unit of the Malartic Psychiatric Hospital in northern Quebec in the short periods pre- and post-ruling. We then determined the proportion of patients judged not criminally responsible and the proportion diagnosed with substance-induced psychosis. We ran chi-squared tests on the two sets of dichotomous variables. In the period following the Bouchard-Lebrun ruling, a statistically significant decrease was observed in the proportion of individuals judged not criminally responsible, as was a statistically significant increase in the proportion of individuals diagnosed with substance-induced psychosis. The findings suggest that the Bouchard-Lebrun ruling may have had an impact on subsequent forensic psychiatry decision-making and treatment at the Malartic Hospital.

Emotional and behavioral dysregulation are common in severe mental illnesses, including schizophrenia, bipolar disorder, and borderline personality disorder. Emotional instability and behavioral outbursts can be driven by internal processes and/or environmental triggers and interpersonal interactions. Understanding the underlying diagnosis is important in determining the best course of treatment. Disorder-specific treatments are important in addressing underlying drivers of emotional dysregulation, irritability, and aggression. Coping skills training and behavioral modification strategies have broad applicability and are useful for aggression and irritability. Treatment planning to address emotion dysregulation and aggression in severe mental illness should address psychiatric comorbidities, substance use, and medication adherence.

Intentional homicide, a declining phenomenon in Italy, represents one of the most extreme forms of violence. A specific subgroup of homicidal assailants is represented by those affected by mental disorders, where the relationship between psychopathology and characteristics of the homicidal attack is not yet fully understood. We analyzed the case files of 187 homicides or attempted homicides, in which the defendant had undergone a forensic psychiatric evaluation within the previous 10 years from a single forensic psychiatric center. We described and analyzed the perpetrator, victim and criminological characteristics of the study cases. A diagnosis of a schizophrenia spectrum disorder, a victim who was the perpetrator's biological child and absence of a personality disorder diagnosis were associated with an increased probability of having been adjudicated as lacking or having substantially diminished criminal responsibility due to a mental disorder. Homicidal assailants with a schizophrenia spectrum disorder showed some differences in criminological characteristics compared with murderers without a schizophrenic spectrum disorder, including a higher incidence of parricide, interruption of pharmacotherapy before the crime and disorganized post-crime behavior.

The research evidence is very strong for high recidivism rates of violence after discharge from forensic facilities. Big data research has found that a substantial proportion of the forensic population with relapse into violence has a psychosis diagnosis and a criminal record. However, more research on the association between psychotic symptoms and violence may inform and enhance risk assessment, prevention, and treatment. We conducted a prospective naturalistic study with a repeated measures design in a sample of 22 psychotic patients during follow-up after discharge from forensic mental health facilities. We had three aims: to test the predictive validity of three psychotic symptom scales for violence, to analyze main and interaction effects between psychotic symptoms and previous criminal conviction, and to explore the feasibility and potential benefit of the repeated measures design for prospective follow-up research. Interpreted within the limitation of the small sample size, the results were promising for all scales, particularly for adjusted effects without interaction. Two scales remained significant when their interaction with criminal conviction was adjusted. This indicates that risk judgment of psychotic patients with criminal conviction can be improved by adding measurement of fluctuations in psychotic symptoms. The repeated measures design was instrumental in this research.

Little is known whether differences exist in motivation and reactive/instrumental offense behaviors between murder offenders with and without psychotic disorder. To contribute to better prevention strategies, the aim of this study was to investigate offense characteristics in murder offenders with a psychotic, nonpsychotic or no psychiatric diagnosis, and whether these factors differ according to sex. This data study examined the population of murder offenders between 1997 and 2005 (N = 435) in Victoria, Australia. Apparent motive for murder was allocated to one of six classifications. Assignations of reactive versus instrumental offense categories, co-offending, victim-offender relationship were determined by review of case material. Mental health service usage and prevalence of mental illnesses were identified through data with the statewide register of contacts with the public mental health system. Of the 435 offenders, 43 (9.9%) had been diagnosed with a psychotic illness. Gender differences between and within offenders with and without a psychotic disorder were analyzed. Murder offenders with a psychotic disorder were 3.19 (95% confidence interval [CI] = [1.27, 8.03]) times more likely to be motivated by revenge than nonpsychotic offenders and those with no diagnosis (odds ratio [OR] = 2.46, 95% CI = [1.10, 5.53]). The diagnostic groups did not differ on premeditation of their offenses or prior convictions. Perpetrators with psychotic illness were significantly more likely to kill family members and others known to them. It appears that for the psychotic disorder group, the perception of having been wronged in some way is a potential risk marker for planning and committing a serious offense. Care should be taken to improve adherence and access to care to avoid possible future serious violence especially in female patients with a high burden of mental illness like schizophrenia or severe mood disorders.

The aim of this study was to compare the baseline characteristics (demographic, psychiatric-psychopathological and legal) among Greek forensic patients found not guilty by reason of insanity. The first step of this approach being differentiating patients who committed a criminal offense during their first psychotic episode from the ones who did so later in the course of their illness. All patients were hospitalized in the Department of Forensic Psychiatry (DFP) of the Psychiatric Hospital of Thessaloniki (PHT) from January 2015 to January 2020 and were examined in order to be included in the study. The final research sample consisted of 78 patients (70 identifying themselves as males and 8 identifying themselves as females) aged 18 and older, 21 of whom committed a criminal offense during their first psychotic episode (FEP, N = 21) and 57 did so later on in the course of their illness (Course, N = 57). Data were collected from multiple sources and several psychometric tools were used (Mini International Neuropsychiatric Interview-M.I.N·I, Positive And Negative Syndrome Scale-PANSS, Addiction Severity Index-ASI, CAGE Questionnaire, Hostility and Direction of Hostility Questionnaire-HDHQ, Global Assessment of Functioning-GAF and Aggression Questionnaire). Comparing the two groups (FEP vs. Course) we found that patients in FEP were younger, had experienced stressful life events in the last 24 months, committed more serious violent crimes, and more frequently attempted suicide after the crime. Their victims were usually members of their family. The main psychometric disparities between the two groups were found in the "Hostility" score of the Aggression questionnaire, and the items "Criticism of Others" and "Paranoid Hostility" of the HDHQ questionnaire, where patients in FEP scored lower. Patients in FEP scored significantly higher in items P1 (delusions), P4 (excitement), P6 (suspiciousness/persecution) and P7 (hostility) of the PANSS scale. No statistically significant differences were found between the two groups regarding their evaluation with the CAGE, ASI or GAF questionnaires. When comparing the patients' present scores in PANSS scale, the patients in FEP had lower total scores in the Positive and the General Psychopathology subscales. Both groups showed significant improvement during hospitalization in all scales (PANSS & GAF), except for the Negative Subscale of the PANSS scale. Through logistic regression analysis, we found that patients in FEP were younger, more likely to have recently experienced stressful life events and more likely to have assaulted a member of their family. Patients with higher scores in the "Hostility" subscale of the Aggression questionnaire were found to remain at risk for committing a crime during the course of their illness. These findings underline the need to design and develop specialized mental health services in order to identify and treat patients involved in violent crime in a timely and effective manner addressing their multiple needs.

Mass shootings account for a small fraction of annual worldwide murders, yet disproportionately affect society and influence policy. Evidence suggesting a link between mass shootings and severe mental illness (i.e. involving psychosis) is often misrepresented, generating stigma. Thus, the actual prevalence constitutes a key public health concern.

We examined global personal-cause mass murders from 1900 to 2019, amassed by review of 14 785 murders publicly described in English in print or online, and collected information regarding perpetrator, demographics, legal history, drug use and alcohol misuse, and history of symptoms of psychiatric or neurologic illness using standardized methods. We distinguished whether firearms were or were not used, and, if so, the type (non-automatic v. semi- or fully-automatic).

We identified 1315 mass murders, 65% of which involved firearms. Lifetime psychotic symptoms were noted among 11% of perpetrators, consistent with previous reports, including 18% of mass murderers who did not use firearms and 8% of those who did (χ2 = 28.0, p < 0.01). US-based mass shooters were more likely to have legal histories, use recreational drugs or misuse alcohol, or have histories of non-psychotic psychiatric or neurologic symptoms. US-based mass shooters with symptoms of any psychiatric or neurologic illness more frequently used semi-or fully-automatic firearms.

These results suggest that policies aimed at preventing mass shootings by focusing on serious mental illness, characterized by psychotic symptoms, may have limited impact. Policies such as those targeting firearm access, recreational drug use and alcohol misuse, legal history, and non-psychotic psychopathology might yield more substantial results.

The goal of the current study was to investigate the socio-demographic, psychiatric, and criminological characteristics of female violent offenders with mental disorders involuntarily committed to a forensic psychiatric hospital. The present study was a population-based retrospective case series including all female offenders with mental disorders found not guilty by reason of insanity by the criminal courts in the state of Rio de Janeiro, Brazil, and involuntarily committed to a forensic psychiatric facility (n = 27). Patients were assessed with Structured Clinical Interview for DSM-IV Axis I Disorders and the Positive and Negative Syndrome Scale. We found that most offenders were Afro-Brazilian, uneducated unmarried women. Schizophrenia with active psychotic symptoms was the most common clinical condition. Relatives were the frequent victims of aggressive behavior. Most patients had already been diagnosed with a mental disorder and placed under psychiatric treatment, but poor adherence and treatment dropout were common. Violent behavior in psychiatrically ill female patients is associated with a specific socio-demographic and clinical profile and is thus potentially amenable to prevention particularly if the mental health and social services are to provide the much-needed support for economically, socially, and psychologically vulnerable women.

Violence and aggression are common problems encountered in prison, which frequently require clinical intervention. This increased prevalence is partially attributable to the high morbidity of psychiatric and personality disorders in prison inmates. As prisons are non-therapeutic environments, the provision of clinical care becomes more complex. This article examines the general principles of management of violence and aggression in prison settings, with a particular focus on the clinical and ethical considerations that guide pharmacological approaches. Use of psychotropic medication to address these problems is reserved for situations where there is (i) a diagnosable psychiatric disorder, or (ii) a significant risk of harm to an individual without urgent intervention. Initial focus should be on environmental and behavioural de-escalation strategies. Clear assessment for the presence of major mental illness is crucial, with appropriate pharmacological interventions being targeted and time-limited. Optimising management of any underlying psychiatric conditions is an important preventative measure. In the acute setting, rapid tranquilisation should be performed according to local guidelines with a focus on oral prior to parenteral administration. Clinicians must be mindful of capacity and consent issues amongst prisoners to protect patient rights and guide setting of care.

Risk of contact with the criminal justice system (CJS) is greater among those with mental illness, including severe mental illness-an observation that many argue reflects a process of "criminalizing" mental illness. Forensic patients represent a subgroup at one end of a spectrum of such criminalization, typically with histories of serious violence and psychotic illness. Strategies for decriminalizing mental illness in this context should consider a range of approaches, including intervening to prevent CJS contact in those with severe mental illness, particularly in the early or emerging stages of psychosis. However, it may be that even gold standard mental healthcare applied universally is insufficient to address CJS contact risks. While there is now an extensive literature documenting the relatively low rates of repeat CJS contact for forensic patients released from secure care, appropriate comparison groups are lacking and the key ingredients of any benefits of treatment are unknown. The CJS may well have something to learn from forensic mental health systems and services given the abject failure to stem rates of prison-release reoffending internationally. Understanding how to best identify risk and effectively intervene to prevent CJS contact in those with mental illness, whether early in the course of psychosis or following release from secure care, remains a priority for those seeking to address the criminalization of mentally illness in our communities.

Schizophrenia is associated with significant health, social, occupational, and economic burdens, including increased mortality. Despite extensive and robust research on the treatment of individuals with schizophrenia, many individuals with the illness do not currently receive evidence-based pharmacological and nonpharmacological treatments. The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia, Third Edition, aims to enhance knowledge and increase the appropriate use of interventions for schizophrenia, thereby improving the quality of care and treatment outcomes. To this end, this evidence-based Performance in Practice tool can facilitate the implementation of a systematic approach to practice improvement for the care of individuals with schizophrenia. This practice assessment activity can also be used in partial fulfillment of Continuing Medical Education and Maintenance of Certification, part IV, requirements, which can also satisfy requirements for the Centers for Medicare & Medicaid Services Merit-based Incentive Payment System program.

Many studies have established a correlation between the increase of homicide rates, and economic crises and rapid social changes following historical events. We propose to analyse the impact of the Tunisian Revolution on homicide rates in Tunisia in a clinical population.

We conducted a retrospective comparative study of all individuals who commited an homicide and were admitted, at least once, to the forensic psychiatry unit in Razi Hospital between January 1st, 2004 and December 31st, 2018 after a decision of irresponsibility by reason of insanity.

The number of homicides committed by the individuals with mental illness included in our study was multiplied by a factor of 1.3 after the revolution, with a prevalence of 11.0% between 2004 and 2011, compared to a prevalence of 14.7% during the period 2011-2018. No significant difference was noted between the two groups regarding the socio-demographic characteristics or the characteristics of the act committed.

Our results highlighted that political and socio-economic crises following the Tunisian revolution significantly contributed to an increase of homicide rates in people with severe mental illness. Thus, macro-level socioeconomic determinants would be important to consider in homicide prevention strategies.

The present study was designed to compare gender differences in psychiatric diagnosis with the dimension of psychopathy in women and men who had attempted or committed homicide. The study samples consisted of 39 homicidal females and 48 homicidal males who were confined in one of Italy's REMS or prison facilities in two southern provinces of Italy (Puglia and Basilicata). Assessment instruments included the SCID-5, the PID-5 IRF, and the PCL-R. Each gender group was stratified according to the level of criminal responsibility for the homicidal offense (full, partial, absent), and after assessments, according to the degree of the psychopathic dimension. There were clear gender differences in homicidal individuals. Female offenders were less likely to have had a record of criminal charges/convictions or imprisonment, and their homicides were more often intrafamilial, victimizing especially of their children, whereas males targeted intimate partners and extrafamilial victims. In the entire group, there was an inverse relationship between the level of psychopathy and the personality disorder on one side, and the psychotic disturbance on the other. Factor 2 (lifestyle/antisocial dimension) of the PCL-R was higher among the homicidal males, whereas females tended to score higher on Factor 1 (the interpersonal/affective dimension). Finally, if the psychopathic dimension is a qualifier for antisocial personality disorder, as indicated in DSM-5, this appears to be less true for females who tend to have other personality disorders.

Aggressive and violent behavior, including both verbal and physical aggression, have considerable adverse consequences for people with schizophrenia. There are several potential causes of violent behavior on the part of people with severe mental illness, which include intellectual impairments, cognitive and social-cognitive deficits, skills deficits, substance abuse, antisocial features, and specific psychotic features. This review explores the interventions that have been tested to this date. Computerized Cognitive Training (CCT) or Computerized Social-Cognitive Training (CSCT) have been associated with reductions in violence. Combined CCT and CSCT have been found to improve social cognition and neurocognition, as well as everyday functioning when combined with rehabilitation interventions. These interventions have been shown to reduce violence in schizophrenia patients across multiple environments, including forensic settings. The reductions in violence and aggression have manifested in various ways, including reduced violent thinking and behavior, reduced physical and violent assaults, and reduced disruptive and aggressive behaviors. Effects of cognitive training may be associated with improvements in problem-solving and the increased ability to deploy alternative strategies. The effect of social cognition training on violence reduction appears to be direct, with improvements in violence related to the extent of improvement in social cognition. There are still remaining issues to be addressed in the use of CCT and CSCT, and the benefits should not be overstated; however, the results of these interventions are very promising.

To investigate patterns of mental health service and antipsychotic use following a first-episode schizophrenia (FES) and to examine the role of the treatment setting in which individuals are first diagnosed.

Analysis of de-identified administrative claims data from the OptumLabs Data Warehouse was used to identify 1450 privately insured youth and young adults aged 14 through 30 with FES from January 1, 2011 through December 31, 2015. Regression analysis was used to estimate the use of mental health services during the year following FES, by type of service and by site of index diagnosis.

In the year following FES, 79.7% of youth received outpatient mental health services and 35.8% filled a prescription for antipsychotic medication. Among service users, mean outpatient visits were 15.9 and mean antipsychotic fills were 8.3. Youth who received an index diagnosis of FES in an inpatient setting were more likely to fill an antipsychotic medication than youth with FES in other settings. Youth who received an index diagnosis of FES during a specialty mental health outpatient visit had greater use of outpatient mental health than youth who received their diagnosis during a primary care visit.

Despite evidence-based guidelines supporting outpatient psychosocial care and antipsychotic treatment for FES, one-fifth of this cohort did not use outpatient services and the majority did not fill any prescriptions for antipsychotic medications during the year following FES. Our findings provide renewed urgency to ongoing efforts to accelerate early identification and care coordination for youth with FES.

It has been suspected that abnormalities in social inference (e.g., learning others' intentions) play a key role in the formation of persecutory delusions (PD). In this study, we examined the association between subclinical PD and social inference, testing the prediction that proneness to PD is related to altered social inference and beliefs about others' intentions. We included 151 participants scoring on opposite ends of Freeman's Paranoia Checklist (PCL). The participants performed a probabilistic advice-taking task with a dynamically changing social context (volatility) under one of two experimental frames. These frames differentially emphasised possible reasons behind unhelpful advice: (i) the adviser's possible intentions (dispositional frame) or (ii) the rules of the game (situational frame). Our design was thus 2 × 2 factorial (high vs. low delusional tendencies, dispositional vs. situational frame). We found significant group-by-frame interactions, indicating that in the situational frame high PCL scorers took advice less into account than low scorers. Additionally, high PCL scorers believed more frequently that incorrect advice was delivered intentionally and that such misleading behaviour was directed towards them personally. Overall, our results suggest that social inference in individuals with subclinical PD tendencies is shaped by negative prior beliefs about the intentions of others and is thus less sensitive to the attributional framing of adviser-related information. These findings may help future attempts of identifying individuals at risk for developing psychosis and understanding persecutory delusions in psychosis.