Transcript Psychiatric patients and violent crime

Mental illness in convicted
sexual offenders
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Seena Fazel, University of Oxford,
Dept. of Psychiatry
Niklas Langstrom, Gabrielle Sjostedt,
Martin Grann, Centre for Violence
Prevention, Karolinska Institute
Funded by the NHS R&D Programme in
Forensic Mental Health
Background statistics
Huge burden of morbidity
 13% women, 2% men raped
 25% women sexually coerced
Increasing problem?
 Doubling of rapes reported to police and
convictions in Australia, Canada, Holland,
Sweden and UK in the 1990s
 In the UK, 60,000 sexual offences reported
 UK rapes: 1068 (in 1980) to 14,000 (in 2004)
Pattern of convictions by age in England and Wales as % of
all convictions for the respective offence group
45
40
35
30
10 to 20
21 to 29
60 to 99
25
20
15
10
5
0
Violence
Sexual
Theft
Drugs
Pattern of convictions within their age group
as % of total offences
Drugs
Criminal Damage
Fraud
Theft & Handling
Robbery
Burglary
Sexual
Violence
10 to 20
21 to 29
60 to 99
Mental illness and sexual offending?
Previous work
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Violence – clear evidence that severe mental
illness (SMI) is a risk factor
Sexual offending – expert opinion discounts
relationship with SMI (Cf. Faulk’s textbook,
articles by Hanson)
Population studies: crude OR = 2.7 (Wallace
1998)
Case series: high rates affective illness,
substance abuse, PD (Stinson 2005)
Prison studies: elderly men have higher rates
of certain PD traits (Fazel 2002)
Aims
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Psychiatric morbidity in sentenced
sexual offenders in Sweden
Risk factors for sexual offending
Focus on severe mental illness
National survey 1988-2000
Swedish databases
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All individuals, incl. immigrants, have
unique 12 digit personal identification
number
High quality national registers for
hospitalizations and crime
Hospital discharge register (HDR)
Crime register
Hospital register
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All hospital admissions centrally registered
and given ICD-9/10 discharge diagnosis
Largest inpatient register in the world (9
million population)
Validity for SMI is good (86% concordance for
schizophrenia)
Validity for PD and substance abuse is fair
(Cohen’s kappa 0.2-0.4)
Computerised from 1988
Criminal register
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National criminal register
Sexual offences included rape, indecent
assault, indecent exposure, child molestation
Excluded prostitution, hiring of prostitutes,
possession of child pornography
Conviction data (incl. mental health disposals,
cautions, fines, legally insane, non-custodial)
No plea bargaining in Swedish law
15+ years old
Good quality – 0.05% convictions have
missing identification numbers
Design
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Prevalence study: linkage of crime and
health registers
8495 male and 93 female sexual
offenders
Case-control: 50,000 randomly chosen
individuals, stratified for year of entry,
Those with sexual convictions and
under 15s excluded
Results - demographics
Variable
Cases
Controls
Stats
Age (years)
37.07
45.26
t = -36, p < .001
Income (individual, USD)
9844.12
18934.85
t = -21, p < .001
Income (household, USD)
19994.24
30614.30
t = -25, p < .001
Unemployment (days)
26.10
11.67
t = 20, p < .001
Social welfare
38.0%
5.1%
2 = 4556, p < .001
Single household
67.7%
38.0%
2 = 1839, p < .001
Children
44.4%
44.0%
ns
Immigrant
37.4%
16.2%
2 = 1543, p < .001
Metropolitan area
31.1%
28.0%
2 = 28, p < .001
Tertiary education
9.0%
19.8%
Any non-sexual violent
crime
38.0%
2.7%
2 = 6445, p < .001
Prevalence and risk
Diagnosis
Psychiatric
hosp.
Sex offenders
Control group
Odds Ratio
%
%
Crude
Adjusted*
n
n
24.0
(n = 2
038)
4.7
(n = 928)
6.5 (6.0-7.0)
6.3 (5.7-6.9)
SCZ
1.5
(n = 130)
0.3
(n = 51)
6.1 (4.4-8.4)
4.8 (3.4-6.7)
Bipolar
0.3
(n = 27)
0.1
(n = 20)
3.2 (1.8-5.7)
3.4 (1.8-6.4)
Other
psychoses
2.5
(n = 212)
0.4
(n = 76)
6.7 (5.1-8.7)
5.2 (3.9-6.8)
Organic
0.5
(n = 44)
0.5
(n = 105)
1.0 (0.7-1.4)
2.4 (1.6-3.6)
*Adjusted for age, income, immigrant status
Risk of psychiatric disorders in
sexual offenders
7
6
5
ORs
4
3
2
1
Any hosp
Scz
Bipolar
Other
psychoses
Organic
C
hi
ld
/
ad
o
l
he
r
ot
LD
al
D
c
ep
re
ss
io
A
n
dj
us
tm
en
t
dr
ug
PD
A
nx
ie
ty
Adjusted Odds Ratio
Risk of other psychiatric disorders
31
26
21
16
11
6
1
Rapists vs. child offenders
35
30
Prevalence %
25
20
Rapists
Child
15
10
5
0
Any psych
Other
psychoses
Alc
Drug
PD
Any SUD
Conclusions
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8495 male sexual offenders
10 times larger than previous study
Adjusts for socio-economic confounders
6x increased risk of psychiatric hospitalization
2-5x increased risk of psychoses
Role of SMI in sexual offending
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Potentially important
Contrary to expert opinion
Is this the same story for psychosis and
violent crime?
Mechanism of association
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Psychotic symptoms trigger, cf. special
hospital sample of 12 out of 15 patients
(Phillips 1990)
SMI associated with hostility, cognitive
distortions, deviant fantasies, poor
social skills, which are risk factors
Non-specific disinhibiting factor (+/interact with alcohol or drugs)
Other diagnoses
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More caution warranted because of
diagnostic problems, selection biases
Personality disorder, substance abuse,
child and adolescent disorders
Rapists and child molesters different
patterns of morbidity
Rapists higher rates of substance
abuse, psychoses
Limitations
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13 prevalence
Based on inpatient data
Clinical diagnoses
Official crime data – only 20-30% actual
rapes lead to convictions
Those with SMI disproportionately
caught
Role of psychiatry
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Society moving to harsher sentencing
Improving the detection and treatment
of sexual offenders may reduce
recidivism, morbidity of prisoners, selfharm and suicide in custody??
Further work needed esp. longitudinal
studies