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Criminal Offenses Among Discharged Mentally Ill Individuals
International Journal of Law and Psychiatry, Vol. 21, No. 2, pp. 197–207, 1998 Copyright © 1998 Elsevier Science Ltd Printed in the USA. All rights reserved 0160-2527/98 $19.00 1 .00
PII S0160-2527(98)00012-0
Criminal Offenses Among Discharged Mentally Ill Individuals Determinants of the Duration from Discharge and Absence of Diagnostic Specificity Yuki Satsumi,* Toshiya Inada,** and Tadamitsu Yamauchi***
Introduction Some mentally ill patients commit criminal offenses after release from hospital. Gibbens and Robertson reported that 4% of psychiatric inpatients admitted under to hospital a legal order would eventually commit serious offenses, and that a further 4% would become recidivists (Gibbens & Robertson, 1983). Studying a large community population, Swanson et al. found that while violent behavior was no less frequent among the mentally ill than among mentally healthy individuals, the risk of committing it was increased, though only modestly, with the number of psychiatric diagnoses according to the DSM-III criteria (Swanson et al., 1991). They also found that the risk of violent acts among schizophrenics was slightly higher than among normal controls, and that it was markedly elevated when schizophrenia was complicated by coexisting substance use disorders (Swanson et al., 1991). These findings and public concern make mental health professionals doubly responsible for both the question of public security and the care and rehabilitation of patients. Despite ample literature on the prediction and management of offenses and the re-offending rates of discharged psychiatric inpatients (Blomhoff, Feim, & Friss, 1990; Swanson et al., 1990; Bloom, 1989; Fagin, 1976), there has been little study of either the timing of criminal offenses or the demographic, clinical, and criminological features of those patients who commit them within a short *Psychiatric Researcher, National Research Institute of Police Science, National Police Agency, Chiyoda-ku, Tokyo, Japan. **Assistant Director, Department of Geriatric Mental Health, National Center of Neurology and Psychiatry, Chiba, Japan. ***President, Sakuragaoka Memorial Hospital, Institute of Social Welfare, Tama City, Tokyo, Japan. Address correspondence and reprint requests to Dr. Yuki Satsumi, National Research Institute of Police Science, Social Environment Section, 6 Sanbancho, Chiyoda-ku, 102-0075 Tokyo, Japan; E-mail: sat [email protected] 197
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Y. SATSUMI, T. INADA, and T. YAMAUCHI
period of discharge from hospital. However, such data, if available, could be used as reference information for mental health professionals in relation to both the community rehabilitation of discharged patients and the enhancement of public security. The forensic system for mentally ill offenders in Japan is virtually uniform throughout the country. Though some of the district public prosecutor’s offices have a division of psychiatric diagnosis of their own on a regular basis, the rest must refer any case to mental health specialists at the outpatient level. Once an offender is suspected of being mentally ill, the prosecutor does not proceed with the indictment; an expert opinion is usually requested by the public prosecutor’s office before indictment. In this process, the prosecution decides if an offender is mentally ill and therefore not responsible at the time of offense; competence to stand trial is rarely assessed in Japan, and plea-bargaining is not used. The public prosecutor generally refers mentally ill offenders who are acquitted as not guilty by reason of insanity to the prefectural governor for involuntary admission to a psychiatric hospital, in accordance with the Mental Health Law. A brief pretrial examination aims to screen out mentally disordered offenders, while formal psychiatric examination is undertaken in cases that are difficult to diagnose, to support or contest judges’ decisions concerning the responsibility of the mentally ill offender. Thus, an expert opinion may be requested by the prosecution, the defendant, or the court (Satsumi & Oda, 1995). Figure 1 shows a flow chart of the Japanese criminal process for adult offenders. We had the opportunity to analyze a file of cases of pretrial psychiatric examination at a regional public prosecutor’s office, and here we report preliminary results obtained with this data set. Method
Samples The study cohort included 359 offenders (326 male and 33 female) who were suspected of suffering from mental illness by the Nagoya District Public Prosecutor’s Office and referred for pretrial psychiatric examination between January 1, 1987, and December 31, 1991. Their mean age was 38.6 (SD, 11.3) years, and more than 80% (n 5 286) of the subjects were single. The total number of indicted offenses exceeded 359 (n 5 367). Of these 367 offenses, 103 (28%) were larceny, 51 (14%) bodily injury or violence, 42 (11%) homicide, 26 (7%) arson, 22 (6%) intrusion on habitation, and 66 other offenses (18%). Fifty-seven charges (16%) were Special Law offenses. The mean number of prior arrest records was 3.7 (SD, 4.5) and ranged from 0 to 24. In terms of the criminal responsibility judgment, 132 (37%) were identified as irresponsible, 49 (14%) as having diminished responsibility, and 134 (37%) as completely responsible; data on 44 cases (12%) were missing. After the psychiatric examination, 180 offenders (50%) were prosecuted. Applying the International Classification of Disease 9th edition (ICD-9), 111 (31%) were diagnosed as suffering from schizophrenia at the time of the offense, 67 (19%) as having alcohol-related disorders, 22 (6%) as having mental retardation, and 20
CRIMINAL OFFENSES AMONG THE MENTALLY ILL
FIGURE 1. Flow chart of the criminal process for adult offenders. *Suspension of execution of sentence with probationary supervision; **Release on expiration of full prison term; ***Release on expiration of term of protective measures. Excerpted from White Paper on Crime 1992 (1993).
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(6%) as suffering from drug-related disorders. Fourteen (4%) were identified as having a personality disorder, 10 (3%) a neurotic disorder, 9 (3%) a manicdepressive illness, 6 (2%) a paranoid disorder, 6 (2%) an organic mental disorder, and 53 (15%) as not mentally ill. There was no diagnostic information for 41 (12%) cases. The mean frequency of past psychiatric admissions was 1.6 (SD, 2.5), and the mean hospitalization period was 184 (SD, 606) days.
Procedure All the information used in this study was obtained from the pretrial examination reports: it included brief demographic, psychiatric, and criminal data. The demographic variables were age, sex, education, marital status, and occupation. The psychiatric variables consisted of diagnosis according to ICD-9, numbers of hospitals visited, and frequency of both voluntary and involuntary admissions. The involuntary admission system is prescribed in Article 29 of the Mental Health Law (1988). If, as the result of the medical examination, the prefectural governor deems that an examined person is mentally disordered and liable to injure himself or others because of this, the individual is considered to require admission either to a hospital established by the national or prefectural governor, or to a designated hospital. The medical examinations are made by two or more designated physicians, who should agree on the facts about the examined person (Mental Health Law, 1988). The criminal variables consisted of the psychiatric judgment of criminal responsibility, indictment, report of the public prosecutor to the prefectural governor on need for treatment, prior arrest record, charged offense, and information about victims. Article 25 of Mental Health Law states that “when a public prosecutor makes a decision not to institute a public action, when the court judgment . . . has become irrevocable, . . . with regard to a suspect or an accused person, who has been mentally disordered, or is suspected to be mentally disordered, he shall report that effect without delay to the Prefectural Governor” (Mental Health Law, 1988).
Statistical Analysis The data were analyzed in two stages. First, characteristics of all samples with a history of psychiatric hospitalization were illustrated, and factors related to the period from discharge to the offense were analyzed. Second, two groups of mentally ill offenders were identified: that of early-arrested offenders (group E, n 5 132), who committed a crime and were arrested within 5 years of the last discharge, and late-arrested offenders (group L, n 5 42), who offended and were arrested after 5 years. The two groups were compared in terms of demographic, clinical, and criminological variables. Statistical analysis was carried out by the SPSSx (Norusis, 1989). T-test, chisquare analysis, and analysis of variance were performed on the data to examine the relationship between each variable and the time intervals between discharge and the offense (discharge-offense interval or D-O interval).
CRIMINAL OFFENSES AMONG THE MENTALLY ILL
201
TABLE 1 Relationship Between Discharge-Offense Interval and Variables
Sex Male Female Marital status Unmarried Prosecution No Prosecuted Report by prosecutor No Yes Arson No Yes Intrusion upon habitation No Yes Rape No Yes Homicide No Yes Violence No Yes Larceny No Yes Robbery No Yes Intimidation No Yes Criminal damage to property No Yes Other criminal offense No Yes *p significance of t test , .05. **p significance of t test , .01
No. cases
Mean (Mo)
SD
157 11
38.6 112.5
63.1 110.3
140
63.0
94.6
81 83
42.7 45.1
66.1 73.7
88 71
44.5 44.0
71.7 69.6
156 12
37.2 124.5
57.7 135.0
156 12
38.7 104.9
62.1 117.1
164 4
43.8 26.8
69.9 16.9
155 13
43.2 46.0
69.0 73.4
134 34
47.5 27.5
74.2 41.2
114 54
49.5 30.7
78.9 39.2
160 8
44.2 27.5
70.2 43.2
165 3
43.9 20.0
69.7 3.6
155 13
45.6 17.9
71.2 24.8
163 5
43.2 50.6
69.3 69.0
t 22.19 21.18 2.22
.04
22.22* 21.94
1.70
2.14
2.10*
2.06*
.67
4.11**
3.10**
2.23
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Y. SATSUMI, T. INADA, and T. YAMAUCHI
Result Of the 359 offenders, 168 (157 male, 11 female) had a history of being admitted to psychiatric hospital. Their mean age was 40.2 (SD, 10.4) years, and 83% (n 5 140) of them were single. Of these 168 offenders, 32% were charged with larceny, 20% with violence, 8% with homicide, 8% with destroying things in general, 7% with intrusion on habitation, 7% with arson, 5% with robbery, 2% with rape, and 7% with other criminal offenses (Table 1). Thirty-nine (23%) committed other Special Law offenses. The mean of prior arrest records was 4.4 (SD, 4.7) and ranged from 0 to 24. In terms of criminal responsibility, 41% were identified as irresponsible and 15% as having diminished responsibility. Those identified as completely responsible constituted almost the same proportion as the irresponsibility group (Table 2). Applying the ICD-9 criteria, 38% were diagnosed as suffering from schizophrenia, 15% as having alcohol-related disorders, and 14% as having drug-related disorders. These three diagnostic groups took precedence in a proportion of two-thirds. Thirteen percent of the 168 offenders were not considered mentally ill. The mean frequency of past psychiatric admissions was 3.1 (SD, 2.9). The mean D-O interval was 43.4 months (SD, 69.1), with range between 0 and 355 months. Figure 2 shows the cumulative numbers of subjects by the D-O interval. More than half of the subjects were arrested within 18 months of the last discharge, about 70% within 3 years, and 80% within 5 years. As can be seen from Figure 2, the cumulative numbers of arrested individuals changed from an ascending stage to a plateau stage at 5 years after discharge. The D-O interval for males tended to be shorter than for females (males, mean 38.6 months, SD, 63.1; females, mean 112.5 months, SD, 110.3, r 5 2.19,
TABLE 2 Psychiatric Characteristics of Case Individuals Who Had Been Admitted to a Psychiatric Hospital
No. cases (%) 168 (100.0) Criminal responsibility Irresponsibility Diminished responsibility Complete responsibility Unknown ICD-9 diagnosis Schizophrenia Alcohol-related disorders Drug-related disorders Affective psychoses Mental retardation Organic mental disorders Other psychotic disorders Personality disorders Not mentally ill
69 (41.1) 25 (14.9) 75 (44.6) 3 (1.8) 64 (38.1) 25 (14.9) 24 (14.3) 6 (3.6) 6 (3.6) 3 (1.8) 6 (3.6) 7 (4.2) 22 (13.1)
CRIMINAL OFFENSES AMONG THE MENTALLY ILL
203
FIGURE 2. Case accumulation along D-O interval.
p , .05). The D-O interval was significantly correlated with age (r 5 0.222, p , .01) and with criminal records (r 5 0.163, p , .05), but it showed no significant correlation with the level of education (r 5 0.068, NS). Those individuals who never married (mean 43.7 months) and who had been widowed (mean 118.0 months) had a longer mean D-O interval than those who had been separated (mean 32.7 months) (ANOVA F(162, 3) 5 6.47, p , .01) The mean D-O interval did not differ between diagnostic subgroups: it was 41.7 months (SD, 64.6) among those individuals with schizophrenia or other psychotic disorders (n 5 64) and 44.5 months (SD, 72.1) among those with correlation with the number of past admissions to a psychiatric hospital (t 5 0.166, NS), number of psychiatric hospital visits (r 5 0.097, NS) including both in- and outpatient level, or number of involuntary admissions (r 5 0.088, NS) and mandated discharges (r 5 0.009, NS). In relation to the criminal charges, Table 1 shows that those who were prosecuted for violence, larceny, intimidation, and criminal damage to property had significantly longer D-O intervals than those who were not prosecuted for those charges. On the other hand, those who were prosecuted for arson had a significantly shorter mean D-O interval. Robbery, intrusion on habitation, rape, homicide, fraud, and other Special Law offenses showed no marked pattern of the D-O intervals. Some intercorrelation appeared between the predicting variables. Thus, older age was significantly correlated with poorer education (r 5 0.219, p , .01) and with a greater criminal record (r 5 0.306, p , .01). Higher education also had a significant correlation with a smaller criminal record (r 5 0.193, p , .05). As expected, the number of past admissions to psychiatric hospitals was significantly correlated with the number of hospital visits (r 5 0.643, p , .01), including both in- and outpatient levels. We then divided the subjects into two groups, with cut-off points of specific D-O intervals. Results obtained using the 5-year D-O interval will be pre-
204
Y. SATSUMI, T. INADA, and T. YAMAUCHI
TABLE 3 Comparison Between Early-Offending Group and Late-Offending Group: Stage 1
Group E (n 5 132) mean (SD)
Group L (n 5 36) mean (SD)
t
4.7 (5.0) 0.1 (0.3)
3.0 (3.0) 0.0 (0.0)
2.62* 2.92**
Criminal record Involuntary admission *p significance of t test , .05. **p significance of t test , .01
sented here because this created the most significant differences in a variety of variables. The subjects of the E group were likely to consist of younger and unmarried males (Tables 3 and 4): they had been admitted more frequently to a psychiatric hospital involuntarily (Table 3). The two groups, however, did not differ in their proportions of diagnostic categories. The E group subjects were also characterized by earlier and more frequent charges of intrusion on habitation (Tables 3 and 4). The E group subjects were, however, less likely to be prosecuted for arson (Table 4). Discussion The present study demonstrated that if a mentally ill patient discharged from a psychiatric hospital showed criminal behavior, this would occur within a few years after discharge. Thus, about 80% of those patients discharged TABLE 4 Comparison Between Early-Offending Group and Late-Offending Group: Stage 2
Sex Male Female Marital history Unmarried Divorced Bereaved Separated Arson No Yes Intrusion on habitation No Yes x2 Yates’ correction was applied. *p significance of chi-square test , .05. **p significance of chi-square test , .01
Group E (n 5 32)
Group L (n 5 36)
128 4
29 7
94 36 0 0
28 5 1 2
127 5
29 7
126 6
30 6
x2 9.917**
13.12**
8.226**
4.571*
CRIMINAL OFFENSES AMONG THE MENTALLY ILL
205
from a psychiatric hospital who eventually committed illegal behavior would do so within 5 years of the last discharge. Comparing persons acquitted on the grounds of insanity with mentally ill prisoners transferred to hospital treatment, Silver et al. (1989) reported that within 5 years of discharge, 54% of insanity acquittees and 73% of transferred mentally ill prisoners were re-arrested. The corresponding figures 17 years after discharge were 66% and 78%, respectively. Both these and the present data suggest that discharged mentally ill people are more likely to commit criminal behavior within 5 years of discharge. This does not necessarily mean that all psychiatric inpatients recently discharged have a high probability of committing criminal behavior, but rather that there are some patients who are vulnerable to criminal behavior immediately after discharge. It is interesting that the present finding of a marked decrease in the number of individuals who commit a criminal act within 5 years after discharge is consistent with that reported by Silver et al. (1989). Thus, intensive care and rehabilitation from this viewpoint are needed during that period. Combining the analyses showed that the subjects of E group were more likely to be male, young, maritally separated, with a greater criminal record, and charged with trespassing into a dwelling. Psychiatric diagnostic categories, however, showed no relation to the early commission of criminal behavior. These data in agreement with those in the literature. Thus, Cirincione et al. (1992) found that the arrest rates for violence among discharged psychiatric patients did not differ over diagnostic categories (schizophrenia, substance abuse, and other) even when they were controlled for age, race, and legal status. Rice and Harass (1992) reported that schizophrenic acquittees were less likely to commit another offense upon release, and were certainly no more likely to commit a violent offense than non-schizophrenic offenders. They also found that when current symptomatology related to relatively recent occurrences of violent behavior was controlled for, the initial mental patient or nonpatient status was no longer significantly related to the re-offense (Rice and Harass, 1992). However, Eronen et al. studied homicide offenders with homicide recidivism and reported that schizophrenia increased the odds ratio of additional homicidal behavior in male homicide offenders more than 25 times (1996). Psychiatrists still need to pay attention to the effect of mental illness on violent recidivists It could be concluded that the criminal behavior committed by the mentally ill soon after discharge is due to rather specific social disadvantages that they have experienced, rather than their psychopathology. Leong and his colleagues (1991) pointed out the limiting factors as putative lack of efficacious treatment of mentally ill criminals, insufficient economic support, and individual liberty for solving the criminal and psychiatric recidivism problem. In some prior researches, arrest history, homelessness (Casper, 1995), types of crime and frequency of incarceration (Harris & Koepsell, 1996) were suggested as important factors associated with criminal recidivism in mentally ill offenders. Our finding almost supported their finding that immediately after discharge, young, maritally separated psychiatric patients may well face difficulty in finding accommodation and occupation. Stigmatization of mental illness is still prevalent in Japan: society as a whole is still sensitive about having mentally ill people as members, and a criminal record may result in even more
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Y. SATSUMI, T. INADA, and T. YAMAUCHI
adamant rejection by the community. These social adversities and disadvantages may make the subject more vulnerable to committing further criminal behavior. The finding that the offenses with which these subjects were charged were fairly simple and limited to property also supports our proposal. That the arrest rate reaches a plateau 5 years after discharge suggests that these discharged patients either may overcome social disadvantages after this period, or are readmitted to a psychiatric hospital. The present results indicate several aspects of the criminology of mentally ill subjects. First, the subjects in this study were those referred to a district public prosecutor’s office. Since pretrial psychiatric examination services vary widely among the regions in Japan, the present results do not always represent the current status of mentally ill criminal offenders (Inada et al., 1995). Furthermore, offenders subjected to pretrial examination may not always by mentally ill. Further study should include offenders indicted at other district public prosecutors’ offices. Another aspect of our study design is that we exclusively focused on investigating those patients who were arrested after discharge from a mental hospital. The prospective follow-up of discharged psychiatric patients in general may be warranted, from this viewpoint. In conclusion, our data suggest that social treatment and community rehabilitation require resources concentrated especially within a short period after discharge. The same findings are reported for mentally ill individuals released from jails (Leong et al., 1991; Ermutlu & Canady, 1989). This may lead both to better rehabilitation of the mentally ill and to higher security for the public. These two in combination would be expected to lead stigmatization of mental illness. References Bloom, J. D. (1989). The charter of the danger in psychiatric practice: Are the mentally ill dangerous? Bulletin of the American Academy of Psychiatry and the Law, 17, 241–255. Blomhoff, S., Feim, S., & Friss, S. (1990). Can prediction of violence among psychiatric inpatients be improved? Hospital and Community Psychiatry, 41, 771–775. Casper, E. S. (1995). Identifying multiple recidivists in a state hospital population. Psychiatric Service, 46, 1074–1075. Cirincione, C., Steadman, H. J., Robbins, P. C., et al. (1992). Schizophrenia as a contingent risk factor for criminal violence. International Journal of Law and Psychiatry, 15, 347–358. Ermutlu, I. M., & Canady, J. L. (1989). Mental illness, substance abuse, and criminal behavior. Journal of the Medical Association of Georgia, 78, 213–217. Eronen, M., Hakola, P., & Tiihonen, J. (1996). Factors associated with homicide recidivism in a 13-year sample of homicide offenders in Finland. Psychiatric Service, 47, 403–406. Fagin, A. (1976). The policy implications of predictive decision making: “Likelihood” and “dangerousness” in civil commitment proceedings. Public Policy, 24, 491–528. Gibbens, T. C. N., & Robertson, G. (1983). A survey of the criminal careers of hospital order patients. British Journal of Psychiatry, 143, 362–369. Harris, V., & Koepsell, T. D. (1996). Criminal recidivism in mentally ill offenders: A pilot study. Bulletin of American Academy of Psychiatry and Law, 24, 177–186. Inada, T., Minagawa, F., Iwashita, S., et al. (1995). Mentally disordered criminal offenders: Five years’ data from Tokyo District Prosecutors Office. International Journal of Law and Psychiatry, 18, 117–127. Leong, G. B., Silva, J. A., & Weinstock, R. (1991). Dangerous mentally disordered criminals: Unresolvable societal fear? Journal of Forensic Science, 36, 210–218. Mental Health Law. (1988). The Mental Health Division of the Health Service Bureau of the Ministry of Health and Welfare of Japan.
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Norusis, M. J. (1989). SPSS Base System User’s Guide. Chicago: SPSS Inc. Rice, M. E., & Harass, G. T. (1992). A comparison of criminal recidivism among schizophrenic and nonschizophrenic offenders. International Journal of Law and Psychiatry, 15, 397–408. Satsumi, Y., & Oda, S. (1995). Mentally ill offenders referred for psychiatric examination in Japan: Descriptive statistics of a university unit of forensic assessment. International Journal of Law and Psychiatry, 18, 323–331. Silver, S. B., Cohen, M. I., & Spodak, M. K. (1989). Follow up after release of insanity acquittees: Mentally disordered offenders, and convicted felons. Bulletin of American Academy of Psychiatry and Law, 17, 387–400. Swanson, J. W., Holzer, C. E., III., Ganju, V., et al. (1990). Violence and psychiatric disorder in the community: Evidence from the Epidemiologic Catchment Area surveys. Hospital and Community Psychiatry, 41, 761–770. Swanson, J. W., Holzer, C. E., III., Ganju, V. K., et al. (1991). Violence and ECA data. Hospital and Community Psychiatry, 42, 954–955. White Paper on Crime 1992. (1993). The Ministry of Justice of Japan.
PII S0160-2527(98)00012-0
Criminal Offenses Among Discharged Mentally Ill Individuals Determinants of the Duration from Discharge and Absence of Diagnostic Specificity Yuki Satsumi,* Toshiya Inada,** and Tadamitsu Yamauchi***
Introduction Some mentally ill patients commit criminal offenses after release from hospital. Gibbens and Robertson reported that 4% of psychiatric inpatients admitted under to hospital a legal order would eventually commit serious offenses, and that a further 4% would become recidivists (Gibbens & Robertson, 1983). Studying a large community population, Swanson et al. found that while violent behavior was no less frequent among the mentally ill than among mentally healthy individuals, the risk of committing it was increased, though only modestly, with the number of psychiatric diagnoses according to the DSM-III criteria (Swanson et al., 1991). They also found that the risk of violent acts among schizophrenics was slightly higher than among normal controls, and that it was markedly elevated when schizophrenia was complicated by coexisting substance use disorders (Swanson et al., 1991). These findings and public concern make mental health professionals doubly responsible for both the question of public security and the care and rehabilitation of patients. Despite ample literature on the prediction and management of offenses and the re-offending rates of discharged psychiatric inpatients (Blomhoff, Feim, & Friss, 1990; Swanson et al., 1990; Bloom, 1989; Fagin, 1976), there has been little study of either the timing of criminal offenses or the demographic, clinical, and criminological features of those patients who commit them within a short *Psychiatric Researcher, National Research Institute of Police Science, National Police Agency, Chiyoda-ku, Tokyo, Japan. **Assistant Director, Department of Geriatric Mental Health, National Center of Neurology and Psychiatry, Chiba, Japan. ***President, Sakuragaoka Memorial Hospital, Institute of Social Welfare, Tama City, Tokyo, Japan. Address correspondence and reprint requests to Dr. Yuki Satsumi, National Research Institute of Police Science, Social Environment Section, 6 Sanbancho, Chiyoda-ku, 102-0075 Tokyo, Japan; E-mail: sat [email protected] 197
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Y. SATSUMI, T. INADA, and T. YAMAUCHI
period of discharge from hospital. However, such data, if available, could be used as reference information for mental health professionals in relation to both the community rehabilitation of discharged patients and the enhancement of public security. The forensic system for mentally ill offenders in Japan is virtually uniform throughout the country. Though some of the district public prosecutor’s offices have a division of psychiatric diagnosis of their own on a regular basis, the rest must refer any case to mental health specialists at the outpatient level. Once an offender is suspected of being mentally ill, the prosecutor does not proceed with the indictment; an expert opinion is usually requested by the public prosecutor’s office before indictment. In this process, the prosecution decides if an offender is mentally ill and therefore not responsible at the time of offense; competence to stand trial is rarely assessed in Japan, and plea-bargaining is not used. The public prosecutor generally refers mentally ill offenders who are acquitted as not guilty by reason of insanity to the prefectural governor for involuntary admission to a psychiatric hospital, in accordance with the Mental Health Law. A brief pretrial examination aims to screen out mentally disordered offenders, while formal psychiatric examination is undertaken in cases that are difficult to diagnose, to support or contest judges’ decisions concerning the responsibility of the mentally ill offender. Thus, an expert opinion may be requested by the prosecution, the defendant, or the court (Satsumi & Oda, 1995). Figure 1 shows a flow chart of the Japanese criminal process for adult offenders. We had the opportunity to analyze a file of cases of pretrial psychiatric examination at a regional public prosecutor’s office, and here we report preliminary results obtained with this data set. Method
Samples The study cohort included 359 offenders (326 male and 33 female) who were suspected of suffering from mental illness by the Nagoya District Public Prosecutor’s Office and referred for pretrial psychiatric examination between January 1, 1987, and December 31, 1991. Their mean age was 38.6 (SD, 11.3) years, and more than 80% (n 5 286) of the subjects were single. The total number of indicted offenses exceeded 359 (n 5 367). Of these 367 offenses, 103 (28%) were larceny, 51 (14%) bodily injury or violence, 42 (11%) homicide, 26 (7%) arson, 22 (6%) intrusion on habitation, and 66 other offenses (18%). Fifty-seven charges (16%) were Special Law offenses. The mean number of prior arrest records was 3.7 (SD, 4.5) and ranged from 0 to 24. In terms of the criminal responsibility judgment, 132 (37%) were identified as irresponsible, 49 (14%) as having diminished responsibility, and 134 (37%) as completely responsible; data on 44 cases (12%) were missing. After the psychiatric examination, 180 offenders (50%) were prosecuted. Applying the International Classification of Disease 9th edition (ICD-9), 111 (31%) were diagnosed as suffering from schizophrenia at the time of the offense, 67 (19%) as having alcohol-related disorders, 22 (6%) as having mental retardation, and 20
CRIMINAL OFFENSES AMONG THE MENTALLY ILL
FIGURE 1. Flow chart of the criminal process for adult offenders. *Suspension of execution of sentence with probationary supervision; **Release on expiration of full prison term; ***Release on expiration of term of protective measures. Excerpted from White Paper on Crime 1992 (1993).
199
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(6%) as suffering from drug-related disorders. Fourteen (4%) were identified as having a personality disorder, 10 (3%) a neurotic disorder, 9 (3%) a manicdepressive illness, 6 (2%) a paranoid disorder, 6 (2%) an organic mental disorder, and 53 (15%) as not mentally ill. There was no diagnostic information for 41 (12%) cases. The mean frequency of past psychiatric admissions was 1.6 (SD, 2.5), and the mean hospitalization period was 184 (SD, 606) days.
Procedure All the information used in this study was obtained from the pretrial examination reports: it included brief demographic, psychiatric, and criminal data. The demographic variables were age, sex, education, marital status, and occupation. The psychiatric variables consisted of diagnosis according to ICD-9, numbers of hospitals visited, and frequency of both voluntary and involuntary admissions. The involuntary admission system is prescribed in Article 29 of the Mental Health Law (1988). If, as the result of the medical examination, the prefectural governor deems that an examined person is mentally disordered and liable to injure himself or others because of this, the individual is considered to require admission either to a hospital established by the national or prefectural governor, or to a designated hospital. The medical examinations are made by two or more designated physicians, who should agree on the facts about the examined person (Mental Health Law, 1988). The criminal variables consisted of the psychiatric judgment of criminal responsibility, indictment, report of the public prosecutor to the prefectural governor on need for treatment, prior arrest record, charged offense, and information about victims. Article 25 of Mental Health Law states that “when a public prosecutor makes a decision not to institute a public action, when the court judgment . . . has become irrevocable, . . . with regard to a suspect or an accused person, who has been mentally disordered, or is suspected to be mentally disordered, he shall report that effect without delay to the Prefectural Governor” (Mental Health Law, 1988).
Statistical Analysis The data were analyzed in two stages. First, characteristics of all samples with a history of psychiatric hospitalization were illustrated, and factors related to the period from discharge to the offense were analyzed. Second, two groups of mentally ill offenders were identified: that of early-arrested offenders (group E, n 5 132), who committed a crime and were arrested within 5 years of the last discharge, and late-arrested offenders (group L, n 5 42), who offended and were arrested after 5 years. The two groups were compared in terms of demographic, clinical, and criminological variables. Statistical analysis was carried out by the SPSSx (Norusis, 1989). T-test, chisquare analysis, and analysis of variance were performed on the data to examine the relationship between each variable and the time intervals between discharge and the offense (discharge-offense interval or D-O interval).
CRIMINAL OFFENSES AMONG THE MENTALLY ILL
201
TABLE 1 Relationship Between Discharge-Offense Interval and Variables
Sex Male Female Marital status Unmarried Prosecution No Prosecuted Report by prosecutor No Yes Arson No Yes Intrusion upon habitation No Yes Rape No Yes Homicide No Yes Violence No Yes Larceny No Yes Robbery No Yes Intimidation No Yes Criminal damage to property No Yes Other criminal offense No Yes *p significance of t test , .05. **p significance of t test , .01
No. cases
Mean (Mo)
SD
157 11
38.6 112.5
63.1 110.3
140
63.0
94.6
81 83
42.7 45.1
66.1 73.7
88 71
44.5 44.0
71.7 69.6
156 12
37.2 124.5
57.7 135.0
156 12
38.7 104.9
62.1 117.1
164 4
43.8 26.8
69.9 16.9
155 13
43.2 46.0
69.0 73.4
134 34
47.5 27.5
74.2 41.2
114 54
49.5 30.7
78.9 39.2
160 8
44.2 27.5
70.2 43.2
165 3
43.9 20.0
69.7 3.6
155 13
45.6 17.9
71.2 24.8
163 5
43.2 50.6
69.3 69.0
t 22.19 21.18 2.22
.04
22.22* 21.94
1.70
2.14
2.10*
2.06*
.67
4.11**
3.10**
2.23
202
Y. SATSUMI, T. INADA, and T. YAMAUCHI
Result Of the 359 offenders, 168 (157 male, 11 female) had a history of being admitted to psychiatric hospital. Their mean age was 40.2 (SD, 10.4) years, and 83% (n 5 140) of them were single. Of these 168 offenders, 32% were charged with larceny, 20% with violence, 8% with homicide, 8% with destroying things in general, 7% with intrusion on habitation, 7% with arson, 5% with robbery, 2% with rape, and 7% with other criminal offenses (Table 1). Thirty-nine (23%) committed other Special Law offenses. The mean of prior arrest records was 4.4 (SD, 4.7) and ranged from 0 to 24. In terms of criminal responsibility, 41% were identified as irresponsible and 15% as having diminished responsibility. Those identified as completely responsible constituted almost the same proportion as the irresponsibility group (Table 2). Applying the ICD-9 criteria, 38% were diagnosed as suffering from schizophrenia, 15% as having alcohol-related disorders, and 14% as having drug-related disorders. These three diagnostic groups took precedence in a proportion of two-thirds. Thirteen percent of the 168 offenders were not considered mentally ill. The mean frequency of past psychiatric admissions was 3.1 (SD, 2.9). The mean D-O interval was 43.4 months (SD, 69.1), with range between 0 and 355 months. Figure 2 shows the cumulative numbers of subjects by the D-O interval. More than half of the subjects were arrested within 18 months of the last discharge, about 70% within 3 years, and 80% within 5 years. As can be seen from Figure 2, the cumulative numbers of arrested individuals changed from an ascending stage to a plateau stage at 5 years after discharge. The D-O interval for males tended to be shorter than for females (males, mean 38.6 months, SD, 63.1; females, mean 112.5 months, SD, 110.3, r 5 2.19,
TABLE 2 Psychiatric Characteristics of Case Individuals Who Had Been Admitted to a Psychiatric Hospital
No. cases (%) 168 (100.0) Criminal responsibility Irresponsibility Diminished responsibility Complete responsibility Unknown ICD-9 diagnosis Schizophrenia Alcohol-related disorders Drug-related disorders Affective psychoses Mental retardation Organic mental disorders Other psychotic disorders Personality disorders Not mentally ill
69 (41.1) 25 (14.9) 75 (44.6) 3 (1.8) 64 (38.1) 25 (14.9) 24 (14.3) 6 (3.6) 6 (3.6) 3 (1.8) 6 (3.6) 7 (4.2) 22 (13.1)
CRIMINAL OFFENSES AMONG THE MENTALLY ILL
203
FIGURE 2. Case accumulation along D-O interval.
p , .05). The D-O interval was significantly correlated with age (r 5 0.222, p , .01) and with criminal records (r 5 0.163, p , .05), but it showed no significant correlation with the level of education (r 5 0.068, NS). Those individuals who never married (mean 43.7 months) and who had been widowed (mean 118.0 months) had a longer mean D-O interval than those who had been separated (mean 32.7 months) (ANOVA F(162, 3) 5 6.47, p , .01) The mean D-O interval did not differ between diagnostic subgroups: it was 41.7 months (SD, 64.6) among those individuals with schizophrenia or other psychotic disorders (n 5 64) and 44.5 months (SD, 72.1) among those with correlation with the number of past admissions to a psychiatric hospital (t 5 0.166, NS), number of psychiatric hospital visits (r 5 0.097, NS) including both in- and outpatient level, or number of involuntary admissions (r 5 0.088, NS) and mandated discharges (r 5 0.009, NS). In relation to the criminal charges, Table 1 shows that those who were prosecuted for violence, larceny, intimidation, and criminal damage to property had significantly longer D-O intervals than those who were not prosecuted for those charges. On the other hand, those who were prosecuted for arson had a significantly shorter mean D-O interval. Robbery, intrusion on habitation, rape, homicide, fraud, and other Special Law offenses showed no marked pattern of the D-O intervals. Some intercorrelation appeared between the predicting variables. Thus, older age was significantly correlated with poorer education (r 5 0.219, p , .01) and with a greater criminal record (r 5 0.306, p , .01). Higher education also had a significant correlation with a smaller criminal record (r 5 0.193, p , .05). As expected, the number of past admissions to psychiatric hospitals was significantly correlated with the number of hospital visits (r 5 0.643, p , .01), including both in- and outpatient levels. We then divided the subjects into two groups, with cut-off points of specific D-O intervals. Results obtained using the 5-year D-O interval will be pre-
204
Y. SATSUMI, T. INADA, and T. YAMAUCHI
TABLE 3 Comparison Between Early-Offending Group and Late-Offending Group: Stage 1
Group E (n 5 132) mean (SD)
Group L (n 5 36) mean (SD)
t
4.7 (5.0) 0.1 (0.3)
3.0 (3.0) 0.0 (0.0)
2.62* 2.92**
Criminal record Involuntary admission *p significance of t test , .05. **p significance of t test , .01
sented here because this created the most significant differences in a variety of variables. The subjects of the E group were likely to consist of younger and unmarried males (Tables 3 and 4): they had been admitted more frequently to a psychiatric hospital involuntarily (Table 3). The two groups, however, did not differ in their proportions of diagnostic categories. The E group subjects were also characterized by earlier and more frequent charges of intrusion on habitation (Tables 3 and 4). The E group subjects were, however, less likely to be prosecuted for arson (Table 4). Discussion The present study demonstrated that if a mentally ill patient discharged from a psychiatric hospital showed criminal behavior, this would occur within a few years after discharge. Thus, about 80% of those patients discharged TABLE 4 Comparison Between Early-Offending Group and Late-Offending Group: Stage 2
Sex Male Female Marital history Unmarried Divorced Bereaved Separated Arson No Yes Intrusion on habitation No Yes x2 Yates’ correction was applied. *p significance of chi-square test , .05. **p significance of chi-square test , .01
Group E (n 5 32)
Group L (n 5 36)
128 4
29 7
94 36 0 0
28 5 1 2
127 5
29 7
126 6
30 6
x2 9.917**
13.12**
8.226**
4.571*
CRIMINAL OFFENSES AMONG THE MENTALLY ILL
205
from a psychiatric hospital who eventually committed illegal behavior would do so within 5 years of the last discharge. Comparing persons acquitted on the grounds of insanity with mentally ill prisoners transferred to hospital treatment, Silver et al. (1989) reported that within 5 years of discharge, 54% of insanity acquittees and 73% of transferred mentally ill prisoners were re-arrested. The corresponding figures 17 years after discharge were 66% and 78%, respectively. Both these and the present data suggest that discharged mentally ill people are more likely to commit criminal behavior within 5 years of discharge. This does not necessarily mean that all psychiatric inpatients recently discharged have a high probability of committing criminal behavior, but rather that there are some patients who are vulnerable to criminal behavior immediately after discharge. It is interesting that the present finding of a marked decrease in the number of individuals who commit a criminal act within 5 years after discharge is consistent with that reported by Silver et al. (1989). Thus, intensive care and rehabilitation from this viewpoint are needed during that period. Combining the analyses showed that the subjects of E group were more likely to be male, young, maritally separated, with a greater criminal record, and charged with trespassing into a dwelling. Psychiatric diagnostic categories, however, showed no relation to the early commission of criminal behavior. These data in agreement with those in the literature. Thus, Cirincione et al. (1992) found that the arrest rates for violence among discharged psychiatric patients did not differ over diagnostic categories (schizophrenia, substance abuse, and other) even when they were controlled for age, race, and legal status. Rice and Harass (1992) reported that schizophrenic acquittees were less likely to commit another offense upon release, and were certainly no more likely to commit a violent offense than non-schizophrenic offenders. They also found that when current symptomatology related to relatively recent occurrences of violent behavior was controlled for, the initial mental patient or nonpatient status was no longer significantly related to the re-offense (Rice and Harass, 1992). However, Eronen et al. studied homicide offenders with homicide recidivism and reported that schizophrenia increased the odds ratio of additional homicidal behavior in male homicide offenders more than 25 times (1996). Psychiatrists still need to pay attention to the effect of mental illness on violent recidivists It could be concluded that the criminal behavior committed by the mentally ill soon after discharge is due to rather specific social disadvantages that they have experienced, rather than their psychopathology. Leong and his colleagues (1991) pointed out the limiting factors as putative lack of efficacious treatment of mentally ill criminals, insufficient economic support, and individual liberty for solving the criminal and psychiatric recidivism problem. In some prior researches, arrest history, homelessness (Casper, 1995), types of crime and frequency of incarceration (Harris & Koepsell, 1996) were suggested as important factors associated with criminal recidivism in mentally ill offenders. Our finding almost supported their finding that immediately after discharge, young, maritally separated psychiatric patients may well face difficulty in finding accommodation and occupation. Stigmatization of mental illness is still prevalent in Japan: society as a whole is still sensitive about having mentally ill people as members, and a criminal record may result in even more
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adamant rejection by the community. These social adversities and disadvantages may make the subject more vulnerable to committing further criminal behavior. The finding that the offenses with which these subjects were charged were fairly simple and limited to property also supports our proposal. That the arrest rate reaches a plateau 5 years after discharge suggests that these discharged patients either may overcome social disadvantages after this period, or are readmitted to a psychiatric hospital. The present results indicate several aspects of the criminology of mentally ill subjects. First, the subjects in this study were those referred to a district public prosecutor’s office. Since pretrial psychiatric examination services vary widely among the regions in Japan, the present results do not always represent the current status of mentally ill criminal offenders (Inada et al., 1995). Furthermore, offenders subjected to pretrial examination may not always by mentally ill. Further study should include offenders indicted at other district public prosecutors’ offices. Another aspect of our study design is that we exclusively focused on investigating those patients who were arrested after discharge from a mental hospital. The prospective follow-up of discharged psychiatric patients in general may be warranted, from this viewpoint. In conclusion, our data suggest that social treatment and community rehabilitation require resources concentrated especially within a short period after discharge. The same findings are reported for mentally ill individuals released from jails (Leong et al., 1991; Ermutlu & Canady, 1989). This may lead both to better rehabilitation of the mentally ill and to higher security for the public. These two in combination would be expected to lead stigmatization of mental illness. References Bloom, J. D. (1989). The charter of the danger in psychiatric practice: Are the mentally ill dangerous? Bulletin of the American Academy of Psychiatry and the Law, 17, 241–255. Blomhoff, S., Feim, S., & Friss, S. (1990). Can prediction of violence among psychiatric inpatients be improved? Hospital and Community Psychiatry, 41, 771–775. Casper, E. S. (1995). Identifying multiple recidivists in a state hospital population. Psychiatric Service, 46, 1074–1075. Cirincione, C., Steadman, H. J., Robbins, P. C., et al. (1992). Schizophrenia as a contingent risk factor for criminal violence. International Journal of Law and Psychiatry, 15, 347–358. Ermutlu, I. M., & Canady, J. L. (1989). Mental illness, substance abuse, and criminal behavior. Journal of the Medical Association of Georgia, 78, 213–217. Eronen, M., Hakola, P., & Tiihonen, J. (1996). Factors associated with homicide recidivism in a 13-year sample of homicide offenders in Finland. Psychiatric Service, 47, 403–406. Fagin, A. (1976). The policy implications of predictive decision making: “Likelihood” and “dangerousness” in civil commitment proceedings. Public Policy, 24, 491–528. Gibbens, T. C. N., & Robertson, G. (1983). A survey of the criminal careers of hospital order patients. British Journal of Psychiatry, 143, 362–369. Harris, V., & Koepsell, T. D. (1996). Criminal recidivism in mentally ill offenders: A pilot study. Bulletin of American Academy of Psychiatry and Law, 24, 177–186. Inada, T., Minagawa, F., Iwashita, S., et al. (1995). Mentally disordered criminal offenders: Five years’ data from Tokyo District Prosecutors Office. International Journal of Law and Psychiatry, 18, 117–127. Leong, G. B., Silva, J. A., & Weinstock, R. (1991). Dangerous mentally disordered criminals: Unresolvable societal fear? Journal of Forensic Science, 36, 210–218. Mental Health Law. (1988). The Mental Health Division of the Health Service Bureau of the Ministry of Health and Welfare of Japan.
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Norusis, M. J. (1989). SPSS Base System User’s Guide. Chicago: SPSS Inc. Rice, M. E., & Harass, G. T. (1992). A comparison of criminal recidivism among schizophrenic and nonschizophrenic offenders. International Journal of Law and Psychiatry, 15, 397–408. Satsumi, Y., & Oda, S. (1995). Mentally ill offenders referred for psychiatric examination in Japan: Descriptive statistics of a university unit of forensic assessment. International Journal of Law and Psychiatry, 18, 323–331. Silver, S. B., Cohen, M. I., & Spodak, M. K. (1989). Follow up after release of insanity acquittees: Mentally disordered offenders, and convicted felons. Bulletin of American Academy of Psychiatry and Law, 17, 387–400. Swanson, J. W., Holzer, C. E., III., Ganju, V., et al. (1990). Violence and psychiatric disorder in the community: Evidence from the Epidemiologic Catchment Area surveys. Hospital and Community Psychiatry, 41, 761–770. Swanson, J. W., Holzer, C. E., III., Ganju, V. K., et al. (1991). Violence and ECA data. Hospital and Community Psychiatry, 42, 954–955. White Paper on Crime 1992. (1993). The Ministry of Justice of Japan.