living in residential facilities
Paper
Giovanni de Girolamo, Valentina Candini, Chiara Buizza, Maria Elena Boero, Clarissa Ferrari, Gian Marco Giobbio, Stefania Greppo, Paolo Maggi, Anna Melegari, Giuseppe Rossi
IRCCS “St. John of God” Fatebenefratelli, Brescia, Italy
Keywords: mental illness, violence, inpatients, residential facilities, recidivism
1. Background
Since the 80s many studies have attempted to investigate the relationship between mental disorders and violence, investigating whether disease severity, comorbidity, the condition of hospitalization and other factors such as age, sex, co-existence of organic disease, number of hospitalization in a mental hospital might be predictors of future violent acts. To date, several variables, which appear to be related to an increased risk of committing violent acts in psychiatric populations, have been identified. An history of violent behaviour, a diagnosis of schizophrenia, especially early onset, the severity of psychiatric symptoms, substances abuse, and the number of previous psychiatric admissions are risk factors for aggressive behaviour in psychiatric patients (McNiel & Binder, 1994; Arango et al., 1999; Steinert et al., 1999).
With regard to the specific Italian situation, the largest study has been realized in the framework of the nationwide project called ‘PROGRES-Acute’ (Preti et al., 2009), which surveyed a large sample of hospitalized patients (N=1,324) in 113 General Hospital Psychiatric Units (GHPUs) and 32 private RFs (Biancosino et al., 2009). The results of this study showed that in a small albeit significant percentage of psychiatric patients violent behaviour is associated with a severe mental disorder, and it occurs particularly in patients with acute disorders requiring hospitalization; thanks to hospital treatment, the dimension of aggression-violence decreases significantly; there are some specific psychopathological dimensions which differentiate psychiatric inpatients who acted and/or act violently from never violent inpatients, the latter representing the majority of patients who require hospital treatment.
With regard to the population with mental disorders admitted to Forensic Mental Hospitals (FMHs), the most important Italian study is the MoDiOPG, a naturalist prospective cohort study. This study showed that the FMHs population is highly complex, with social and health needs, difficult to meet through current care pathways.
Data from this study, and especially the new Italian law on the treatment of patients with mental disorders, authors of violent acts (Law 17, February 2012, n. 9), emphasize the need of a careful investigation of care pathways (Fioritti et al., 2001; 2006). In fact, this law states that all patients currently hospitalized in the 6 Italian FMHs should be discharged and transferred to other RFs, non-judicial but medical.
Therefore, further study is necessary to shed light on the dimension of aggressive behaviour and on the risk of violence in the specific context of the Italian mental health care, in order to identify the most appropriate strategies for prevention and treatment of patients with severe mental disorders which act violently.
The present study is part of a prospective observational cohort study involving St John of God Order’s 23 medium-long term RFs in Northern Italy (de Girolamo et al., 2013), aimed at describing the sociodemographic, clinical, and treatment-related characteristics of RFs patients during an index period, and at identifying discharge-associated predictors and characteristics at 1-year follow-up.
1.1 Aims of the study
Specifics aims of the present study are to investigate the sociodemographic, clinical, and treatment-related characteristics of a sample of male patients living in RFs with an history of violent behaviour (so called
‘violent’ patients); to compare the characteristics of violent patients with residents never violent; to analyse the association between aggressive behaviours (e.g., verbal, physical and sexual) committed in two years of observation and to belong to the two groups (violent vs never violent).
2. Methods
All male patients staying in these medium-long term RFs in September 2010, with a primary psychiatric diagnosis and age of < 65 years were recruited. Exclusion criteria were age 65 years or older, and primary diagnosis of organic mental disorder (i.e. dementia or mental retardation).
The sample was divided into two groups: ‘never violent’ patients and ‘violent’ patients. The violent group included:
1. patients who were at least once in their lifetime in FMHs for violent crimes;
2. patients who were at least once in their lifetime arrested for violent crimes;
3. patients with a life history of violent acts against persons (including sexual violence).
For each inpatient was filled out a ‘Patient Schedule’ composed of BPRS, HONOS, FPS, PHI, SLOF.
Socio-demographic and clinical data were also collected.
The Brief Psychiatric Rating Scale (BPRS) was used to assess psychopathology (Ventura et al., 1997). The Health of Nation Outcome Scale (HoNOS) (Wing et al., 1998) and the Personal and Social Performance (PSP) scale, a modified version of the DSM-IV Social and Occupational Functioning Assessment Scale (SOFAS), were used to assess psychopathology and social functioning (Morosini et al., 2000). The Specific Levels of Functioning (SLOF), recently considered the ‘gold standard’ in this field (Harvey et al., 2011), was administered to assess psychosocial functioning and disability. Cognitive functioning was assessed with the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) (Gold et al., 1999).
Furthermore, a specific module to assess aggressive behaviours lifetime and in the 2-year observation period was used. Aggressive behaviours assessed were: shouting, threatening, pushing others, slapping, punching, inappropriate sexual behaviour, sexual harassment, using weapons. These behaviours were grouped into the following three categories: verbal, physical and sexual aggressive behaviours.
3. Results
3.1 Characteristics of the sample
A total of 268 male patients were assessed at baseline: 81 violent and 187 never violent patients. The mean age of violent patients was 46.5 years (SD= 9.5; median 47), compared to 47.7 (SD= 10.2; median 49) of never violent patients; oveall 45.7% of violent patients were between 18 and 45 years of age, as compared to 38.5 % of the never violent group.
The majority of patients had a schizophrenia spectrum diagnosis (70.5% in violent group, as compared to 83% in the never violent patients). Violent patients were more likely to have a diagnosis of personality disorder (29.5% vs 17%), and this difference was statistically significant (X2=4.825, p=.028).
The mean RF stay duration was 3.1 years (SD=3.5; median 1.9) in the violent group, as compared to 4.0 years (SD=6.5; median 2.1) among the never violent patients; the difference was not statistically significant.
Regarding lifetime compulsory admission, 18 (21.5%) violent patients had none, 40 (50%) patients had 1-3, 22 (27.5%) had more than 4. In the never violent group they were rispectively 105 (57.1%), 50 (27.2%), 32 (15.8%), and the differences between the two group were statistically significant (p<.001).
The mean illness duration was 21.6 years (SD=11.1; median 22) in the violent group, as compared to 22.1 years (SD=12.0; median 20) in the never violent patients.
Concerning the ability to cooperate in the previous year, 47 (58%) patients of the violent group were actively cooperative with the treatment, compared to 104 (55.9%) of the never violent group.
Furthermore, treating clinicians predicted that a higher percentage of never violent patients (N=161, 87.0%) was to remain in the current or in another RFs in the following year, as compared to 60 (74.1%) in the violent group, and this difference was statistically significant (p=.010). Coherently, after one year, 9 (11.8%) patients of the violent group were discharged, as compared to 26 (14.2%) of the never violent patients.
3.2 Assessment scores
At entry, the mean total BPRS score was 59.7 for violent patients and 59.6 for never violent patients: these scores indicate a moderate level of symptoms.
Concerning the specific items of BPRS, there were statistically significant differences between the two groups in hostility (p=.050), grandiosity (p=.046), suspiciousness (p=.040), motor slowing (p=.018), and conceptual disorganization (p=.039).
The HONOS mean total score was also only in a moderate range, with 19.5 for violent patients and 20.0 for never violent patients.
The PSP score showed a significant level of psychosocial impairment. However, violent patient had a higher score, indicating a better functioning, as compared to never violent group (44.2 vs 37.9, p=.001).
About the SLOF, there were statistically significant differences between the two groups in two areas:
‘activities’ (p=.047) and ‘work skills’ (p=.007): also, in this case, violent patients had a higher score, indicating a better functioning. Lastly, the mean total RBANS (neuropsychological status) score was 71.9 for violent patients and 69.9 for never violent group, indicating the presence of a mild cognitive impairment for both groups, without statistically significant differences.
3.3 Differences of aggressive behaviours between the two groups
Table 1 shows the difference in the frequency of aggressive behaviours during the observation period (two years) between violent and never violent patients. There were significant differences between the two groups in the number of aggressive behaviours: the number of aggressive behaviours observed among the violent patients was significantly higher than among never violent patients in all categories of aggressive behaviours assessed: verbal, physical and sexual.
People with severe mental disorders and a history of violent offending are usually seen as a difficult-to-manage population. They are characterized by a high risk of crime recidivism, poor compliance with community programs and aftercare, and homelessness (Teplin, 1990; Coid, 1991; Dolan & Doyle, 2000;
Jamieson & Taylor, 2002). Nevertheless, reintegrating even seriously mentally ill violent offenders into the community may be an achievable outcome, provided that sufficient care resources are allocated to this aim.
In our study, violent patients were younger, with a prevalence of personality disorders. These data are in line with the current literature, which shows that younger patients have a greater chance of displaying violent behaviour (Walker & Caplan, 1993).
Furthermore in our study, the number of aggressive behaviours observed among violent patients was significantly higher than among never violent patients. The presence of a history of serious violent behaviours against people in the past (violent group) was significantly associated with a higher number of verbal, physical and sexual aggressive behaviours.
Consequently, it’s very important to study the characteristics of these patients, in order to organize RFs hosting violent patients as effectively and safely as possible. In fact, very little is known to which extent, and in which way, RFs meet the everyday needs of patients with an history of antisocial behaviour.
Whereas most investigations aimed at evaluating risk of reoffending in this group of patients (Hodgins &
Müller-Isberner, 2004), only very few studies to date have examined these patients’ adjustment after their release from RFs to the community (Heilbrun et al., 1994).
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