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Treating the first episode of schizophrenia earlier will save lives
Schizophrenia Research 92 (2007) 276 – 277 www.elsevier.com/locate/schres
Letter to the Editors Treating the first episode of schizophrenia earlier will save lives Dear Editors, In an editorial following the death of the distinguished researcher Dr Wayne Fenton at the hands of a nineteen year old patient, Dr Fuller Torrey (2006) pointed out the relationship between non-adherence to treatment and an increased risk of violence in schizophrenia. We would also like to draw your readers' attention to the emerging evidence for a greatly increased risk of violence during the first episode of psychotic illness. Three recent studies of homicide during psychotic illness have found that 42% (Meehan et al., 2006), 38% (Appleby and Shaw, 2006) and 61% (Nielssen et al., 2007) of subjects were in their first episode of psychotic illness (FEP) and had yet to receive adequate treatment at the time of the offence. (Table 1) Assuming a prevalence of schizophrenia of 0.5% and an incidence of new cases of around 0.02% of the population in any given year, the risk of homicide during FEP is as much as 20 times higher than the risk after a period of adequate treatment. The finding that homicide and serious violence is far more likely in patients who have not received a period of
adequate treatment is supported by re-examination of other widely cited studies (Hafner and Boker, 1982; Mullen et al., 2000; Wallace et al., 2004). Those studies together with several studies of non-lethal violence (Humphreys et al., 1992; Milton et al., 2001) show the risk of serious violence during FEP is greater than the risks associated with substance abuse, age, socioeconomic status and male gender identified in the largest study of the risk of violence by the mentally ill (Monahan et al., 2001). Poor adherence in previously treated patients may also be a risk factor for homicide but this does not appear to be of the same order of magnitude as the risk in never treated patients. A large proportion of the patients with established illness who committed homicide was taking antipsychotic medication at the time of the offence (Table 1). The rate of adherence to treatment in schizophrenia is known to be poor (Ward et al., 2006) and a proportion of patients have regular acute episodes of illness leading to admission to hospital because of not taking medication, but the incidence of lethal assault during acute episodes in patients with established illness is low. Another important finding among patients who committed homicides during their FEP were that many had very long durations of untreated psychosis (DUP).
Table 1 Recent studies of homicide and treatment status Years
FEP/total
Total Risk of Risk of homicide Inclusion criteria Psychotic FEP homicide in in treated patients homicides per annum a, c per million cases a, b total FEP per annum a
Appleby 1999–2003 53/141 (37.6%) Diagnosis of and Shaw schizophrenia Meehan 1996–1999 36/85 (42.4%) Diagnosis of et al. schizophrenia Nielssen 1993–2003 54/88 (61.4%) Mental illness et al. defence avail a b c
Previously treated patients adherent to medication at the time of the homicide (%)
0.54
36 400
1 in 686
1 in 10 400
51%
0.76
31 200
1 in 866
1 in 17 000
45%
1.4
12 000
1 in 222
1 in 8 800
79%
Assumes a population of 6 million in NSW and 52 million in England and Wales. Assumes an incidence of FEP of 20/100,000/year (Baldwin et al., 2005). Assumes a prevalence of schizophrenia of 0.05% (Jablensky, 2000).
0920-9964/$ - see front matter © 2007 Elsevier B.V. All rights reserved. doi:10.1016/j.schres.2007.02.002
Letter to the Editors
Our international comparison of homicide during FEP found that long DUP was associated with an increased rate of homicide during FEP. We believe that reducing DUP would reduce the incidence of serious violence by the mentally ill, and may reduce suicide during FEP (Altamura et al., 2003; Clarke et al., 2006). Reducing DUP should be an explicit goal of all mental health services. Dr Torrey called for a lower threshold for civil commitment to reduce the incidence of violence by untreated patients. We believe there is a particularly strong case for a lower threshold to treatment for those in their first episode of mental illness. References Altamura, A.C., Bassetti, R., Bignotti, et al., 2003. Clinical variables related to suicide attempts in schizophrenic patients: a retrospective study. Schizophr. Res. 60, 47–55. Appleby, L., Shaw, J., 2006. Five year report of the national confidential inquiry into suicide and homicide by people with mental illness. http://www.medicine.manchester.ac.uk/suicideprevention/ nci/Useful/avoidable_deaths_full_report.pdf. Baldwin, P., Browne, D., Scully, P.J., et al., 2005. Epidemiology of first-episode psychosis: illustrating the challenges across diagnostic boundaries through the Cavan-Monaghan study at 8 years. Schizophr. Bull. 31, 624–638. Clarke, M., Whitty, P., Browne, S., et al., 2006. Suicidality in first episode psychosis. Schizophr. Res. 86, 221–225. Hafner, H., Boker, W., 1982. Crimes of Violence by Mentally Abnormal Offenders: Psychiatric Epidemiological Study in the German Federal Republic. Cambridge University Press. Humphreys, M.S., Johnstone, E.C., MacMillan, J.F., et al., 1992. Dangerous behaviour preceding first admissions for schizophrenia. Br. J. Psychiatry 161, 501–505. Jablensky, A., 2000. Prevalence and incidence of schizophrenia spectrum disorders: implications for prevention. Aust. N.Z. J. Psychiatry 34, S26–S34. Meehan, J., Flynn, S., Hunt, I.M., et al., 2006. Perpetrators of homicide with schizophrenia: a national clinical survey in England and Wales. Psychiatr. Serv. 57, 1648–1651.
277
Milton, J., Amin, S., Singh, S.P., et al., 2001. Aggressive incidents in first-episode psychosis. Br. J. Psychiatry 178, 433–440. Monahan, J., Henry, J., Steadman, H.J., et al., 2001. Rethinking Risk Assessment: The MacArthur Study of Mental Disorder and Violence. Oxford University Press. Mullen, P.E., Burgess, P., Wallace, C., et al., 2000. Community care and criminal offending in schizophrenia. Lancet 355, 614–617. Nielssen, O., Westmore, B., Large, M., et al., 2007. Homicide during psychotic illness in NSW from 1993 to 2002. Med. J. Aust. 186 (6), 301–304. Torrey, E.F., 2006. Violence and schizophrenia. Schizophr. Res. 88, 3–4. Wallace, C., Mullen, P.E., Burgess, P., 2004. Criminal offending in schizophrenia over a 25-year period marked by deinstitutionalization and increasing prevalence of comorbid substance use disorders. Am. J. Psychiatry 161, 716–727. Ward, A., Ishak, K., Proskorovsky, I., et al., 2006. Compliance with refilling prescriptions for atypical antipsychotic agents and its association with the risks for hospitalization, suicide, and death in patients with schizophrenia in Quebec and Saskatchewan: a retrospective database study. Clin. Ther. 28, 1912–1921.
Matthew Large* Olav Nielssen Psychiatrist, Private Practice, 326 South Dowling Street, Paddington 2021, NSW, Australia ⁎ Corresponding author. E-mail address: [email protected] (M. Large). Olav Nielssen Psychiatrist Clinical Research Unit for Anxiety Disorders, School of Psychiatry, UNSW at St Vincent's Hospital, 299 Forbes Street, Darlinghurst, Sydney, NSW 2010, Australia 1 February 2007
Letter to the Editors Treating the first episode of schizophrenia earlier will save lives Dear Editors, In an editorial following the death of the distinguished researcher Dr Wayne Fenton at the hands of a nineteen year old patient, Dr Fuller Torrey (2006) pointed out the relationship between non-adherence to treatment and an increased risk of violence in schizophrenia. We would also like to draw your readers' attention to the emerging evidence for a greatly increased risk of violence during the first episode of psychotic illness. Three recent studies of homicide during psychotic illness have found that 42% (Meehan et al., 2006), 38% (Appleby and Shaw, 2006) and 61% (Nielssen et al., 2007) of subjects were in their first episode of psychotic illness (FEP) and had yet to receive adequate treatment at the time of the offence. (Table 1) Assuming a prevalence of schizophrenia of 0.5% and an incidence of new cases of around 0.02% of the population in any given year, the risk of homicide during FEP is as much as 20 times higher than the risk after a period of adequate treatment. The finding that homicide and serious violence is far more likely in patients who have not received a period of
adequate treatment is supported by re-examination of other widely cited studies (Hafner and Boker, 1982; Mullen et al., 2000; Wallace et al., 2004). Those studies together with several studies of non-lethal violence (Humphreys et al., 1992; Milton et al., 2001) show the risk of serious violence during FEP is greater than the risks associated with substance abuse, age, socioeconomic status and male gender identified in the largest study of the risk of violence by the mentally ill (Monahan et al., 2001). Poor adherence in previously treated patients may also be a risk factor for homicide but this does not appear to be of the same order of magnitude as the risk in never treated patients. A large proportion of the patients with established illness who committed homicide was taking antipsychotic medication at the time of the offence (Table 1). The rate of adherence to treatment in schizophrenia is known to be poor (Ward et al., 2006) and a proportion of patients have regular acute episodes of illness leading to admission to hospital because of not taking medication, but the incidence of lethal assault during acute episodes in patients with established illness is low. Another important finding among patients who committed homicides during their FEP were that many had very long durations of untreated psychosis (DUP).
Table 1 Recent studies of homicide and treatment status Years
FEP/total
Total Risk of Risk of homicide Inclusion criteria Psychotic FEP homicide in in treated patients homicides per annum a, c per million cases a, b total FEP per annum a
Appleby 1999–2003 53/141 (37.6%) Diagnosis of and Shaw schizophrenia Meehan 1996–1999 36/85 (42.4%) Diagnosis of et al. schizophrenia Nielssen 1993–2003 54/88 (61.4%) Mental illness et al. defence avail a b c
Previously treated patients adherent to medication at the time of the homicide (%)
0.54
36 400
1 in 686
1 in 10 400
51%
0.76
31 200
1 in 866
1 in 17 000
45%
1.4
12 000
1 in 222
1 in 8 800
79%
Assumes a population of 6 million in NSW and 52 million in England and Wales. Assumes an incidence of FEP of 20/100,000/year (Baldwin et al., 2005). Assumes a prevalence of schizophrenia of 0.05% (Jablensky, 2000).
0920-9964/$ - see front matter © 2007 Elsevier B.V. All rights reserved. doi:10.1016/j.schres.2007.02.002
Letter to the Editors
Our international comparison of homicide during FEP found that long DUP was associated with an increased rate of homicide during FEP. We believe that reducing DUP would reduce the incidence of serious violence by the mentally ill, and may reduce suicide during FEP (Altamura et al., 2003; Clarke et al., 2006). Reducing DUP should be an explicit goal of all mental health services. Dr Torrey called for a lower threshold for civil commitment to reduce the incidence of violence by untreated patients. We believe there is a particularly strong case for a lower threshold to treatment for those in their first episode of mental illness. References Altamura, A.C., Bassetti, R., Bignotti, et al., 2003. Clinical variables related to suicide attempts in schizophrenic patients: a retrospective study. Schizophr. Res. 60, 47–55. Appleby, L., Shaw, J., 2006. Five year report of the national confidential inquiry into suicide and homicide by people with mental illness. http://www.medicine.manchester.ac.uk/suicideprevention/ nci/Useful/avoidable_deaths_full_report.pdf. Baldwin, P., Browne, D., Scully, P.J., et al., 2005. Epidemiology of first-episode psychosis: illustrating the challenges across diagnostic boundaries through the Cavan-Monaghan study at 8 years. Schizophr. Bull. 31, 624–638. Clarke, M., Whitty, P., Browne, S., et al., 2006. Suicidality in first episode psychosis. Schizophr. Res. 86, 221–225. Hafner, H., Boker, W., 1982. Crimes of Violence by Mentally Abnormal Offenders: Psychiatric Epidemiological Study in the German Federal Republic. Cambridge University Press. Humphreys, M.S., Johnstone, E.C., MacMillan, J.F., et al., 1992. Dangerous behaviour preceding first admissions for schizophrenia. Br. J. Psychiatry 161, 501–505. Jablensky, A., 2000. Prevalence and incidence of schizophrenia spectrum disorders: implications for prevention. Aust. N.Z. J. Psychiatry 34, S26–S34. Meehan, J., Flynn, S., Hunt, I.M., et al., 2006. Perpetrators of homicide with schizophrenia: a national clinical survey in England and Wales. Psychiatr. Serv. 57, 1648–1651.
277
Milton, J., Amin, S., Singh, S.P., et al., 2001. Aggressive incidents in first-episode psychosis. Br. J. Psychiatry 178, 433–440. Monahan, J., Henry, J., Steadman, H.J., et al., 2001. Rethinking Risk Assessment: The MacArthur Study of Mental Disorder and Violence. Oxford University Press. Mullen, P.E., Burgess, P., Wallace, C., et al., 2000. Community care and criminal offending in schizophrenia. Lancet 355, 614–617. Nielssen, O., Westmore, B., Large, M., et al., 2007. Homicide during psychotic illness in NSW from 1993 to 2002. Med. J. Aust. 186 (6), 301–304. Torrey, E.F., 2006. Violence and schizophrenia. Schizophr. Res. 88, 3–4. Wallace, C., Mullen, P.E., Burgess, P., 2004. Criminal offending in schizophrenia over a 25-year period marked by deinstitutionalization and increasing prevalence of comorbid substance use disorders. Am. J. Psychiatry 161, 716–727. Ward, A., Ishak, K., Proskorovsky, I., et al., 2006. Compliance with refilling prescriptions for atypical antipsychotic agents and its association with the risks for hospitalization, suicide, and death in patients with schizophrenia in Quebec and Saskatchewan: a retrospective database study. Clin. Ther. 28, 1912–1921.
Matthew Large* Olav Nielssen Psychiatrist, Private Practice, 326 South Dowling Street, Paddington 2021, NSW, Australia ⁎ Corresponding author. E-mail address: [email protected] (M. Large). Olav Nielssen Psychiatrist Clinical Research Unit for Anxiety Disorders, School of Psychiatry, UNSW at St Vincent's Hospital, 299 Forbes Street, Darlinghurst, Sydney, NSW 2010, Australia 1 February 2007