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Violence among persons diagnosed with schizophrenia: How pharmacists can help
Available online at www.sciencedirect.com
Research in Social and Administrative Pharmacy 7 (2011) 421–429
Commentary
Violence among persons diagnosed with schizophrenia: How pharmacists can help Emily N. Stilwell, Pharm.D. Candidatea, Sarah E. Yates, J.D. Candidateb, Nancy C. Brahm, Pharm.D., M.S.a,* a
Department of Pharmacy Practice, Clinical and Administrative Sciences, 4502 E. 41st Street, Tulsa, OK 74135-2512, USA b The University of Tulsa College of Law, 3120 East 4th Place, Tulsa, OK 74104, USA
Abstract Violence among those diagnosed with schizophrenia has been reported but is not a diagnostic component of the disorder. The position of the courts regarding fulfillment of the requisite intent to commit violent acts has not been extensively reported. This article discusses the impact of a diagnosis of schizophrenia in an individual and how the pharmacist can help integrate information into the health care system. The recent Supreme Court case of Clark versus Arizona and the older case of Patterson versus Cockrell are discussed with respect to the concept of intent (to commit the act) and the implications this has on an individual in the midst of a psychotic episode. Quality of life, the perception of the stigma associated with a diagnosis of schizophrenia, and pharmacotherapy are briefly discussed. The origin of schizophrenia is multifactorial. Persons with schizophrenia are not innately violent, but alteration in perception may precipitate aggressive acts. Given the complex and diverse nature of schizophrenia and the fact that even with successful pharmacological treatment residual symptoms may still be present, there is a need to provide information to health care practitioners and the court. Ó 2011 Elsevier Inc. All rights reserved. Keywords: Schizophrenia; Violence; Constitutional; Mens rea
Introduction Based on Greek roots schizo (split) and phrene (mind), the term ‘‘schizophrenia’’ is approaching the 100-year point. Swiss psychiatrist Eugene Bleuler first used the term in 1911 and separated the symptoms into ‘‘positive’’ or ‘‘negative’’ categories.1 The etiology is still largely unknown; therefore, scientists can only base their classifications on the observation of symptom occurrence. The
most recent criteria based on the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision) define schizophrenia as a disorder occurring for the time of at least 6 months, with a minimum of 1 month of active symptoms that can include positive and negative symptoms2 and problems in cognition (Table 1). In addition, subsets of the disorder have been identified: paranoid, disorganized, catatonic, residual, and undifferentiated. For the purposes of this
* Corresponding author. University of Oklahoma College of Pharmacy, 4502 E. 41st Street, 2H17, Tulsa, OK 741352512, USA. Tel.: þ1 918 660 3579; fax: þ1 918 660 3009. E-mail address: [email protected] (N.C. Brahm). 1551-7411/$ - see front matter Ó 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.sapharm.2010.11.002
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Table 1 Examples of schizophrenia-associated symptoms Positive
Negative
Cognitive
Delusions
Lack of emotional expressiveness (affective flattening) Poverty of speech (alogia) Loss of joy (anhedonia) Avolition Inability to speak Lack of initiative
Inhibition
Hallucinations Suspiciousness Disorganized behavior Disorganized speech (schizophasiaa)
Impaired working memory
a
Schizophasia: moving quickly from topic to topic, without any logical progression. The words used may also have no meaning or association with one another. Data from American Psychiatric Association2 and Schultz et al.11
article, schizophrenia will be discussed broadly with differentiation as needed. Determining whether or not violence is an inherent component in patients with schizophrenia is critical. Currently, modern society still views persons with schizophrenia as violent per se, and the stigma of schizophrenia for patients is profound. Such a stereotype precipitates a fear of those with schizophrenia and an assumption of violent behavior. However, violence is not included either in the formal diagnostic criteria or as a characteristic of one of the subsets nor has the disorder itself been conclusively linked to violent behavior. This article is an effort to illuminate the likely and unlikely connections between schizophrenia and violent behavior.
Schizophrenia: violence assumptions Stigma of schizophrenia The mention of mental illness throughout history and among certain cultures is met with a negative connotation. Beliefs about persons with mental illness range from believing they are dangerous to believing they somehow contributed to their own illness. Persons with schizophrenia are most likely the population that experiences the majority of this stigma. It has been found that beliefs regarding ‘‘social inappropriateness’’ and ‘‘unpredictability and dangerousness’’ are indicators for how individuals in the general public behave toward persons with schizophrenia.3 Persons with schizophrenia are not usually violent; they are more likely to harm themselves than another individual. Suicide attempts and completions are very common.4 Hewitt4 suggests that it is the burden of having to live with a chronic mental disorder that leads these individuals to self-harm and suicide.
One study showed that 66% of individuals surveyed in the health care field hold attitudes that persons with schizophrenia are ‘‘dangerous.’’5 These beliefs only compound the monumental problem persons with schizophrenia already facedthe chronic nature of their illness. Discriminatory effects almost constitute a ‘‘second illness,’’ which manifests in several ways from interpersonal relationships to social roles.6 Stigma associated with schizophrenia may result in patients waiting longer to seek treatment. A recent study focusing on stigma and discrimination toward persons diagnosed with schizophrenia and their families found that most negative experiences resulted from health care settings and family.6 The study also found that individuals in this cohort tended to keep to themselves. The researchers hypothesized that this was a coping strategy used to protect themselves from facing rejection in social settings.6 However, in family settings, they felt that they were overprotected. Comparatively in health care settings, these individuals felt their concerns were not heard or taken into consideration. The discrimination and stigma faced by these persons in the health care field is a reason for concern because this is the avenue in which these individuals use to gain integration into society and seek help for their illness.5 Because it has been shown that stigma and discrimination occur in health care settings where it is presumed providers have a better knowledge base than the general public, this bias may carry over into the legal system. Societal application of stigma The perception of violence as a component of schizophrenia was brought to the public’s attention by a recent Supreme Court case, Clark versus Arizona. This case involved an adolescent
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diagnosed with schizophrenia who murdered a police officer acting in the line of duty. Eric Clark, aged 17 years at that time, believed the police officer was a hostile alien trying to kill him. Clark was actively psychotic with both hallucinations and delusions. The symptoms had been persistent for some time. Clark also believed the entire town in which he lived was populated by aliens. The hallucinations affected Clark to the extent that he had his room at his parents’ home set up with security alarms and would only eat food that was sealed in a package, in fear of being poisoned.7 In an attempt to drown out the voices he heard, Clark had turned the volume of his radio up to its maximum volume. The noise level prompted a call to the police who were sent to Clark’s home to remedy the situation. Another example is the case of Patterson versus Cockrell. In this case, Kelsey Patterson suffered from well-documented paranoid schizophrenia and multiple encounters with police and the legal system. In 2004, Patterson, without motive, shot and killed 2 individuals. After the double murder, he made no effort to conceal the crimes; instead he returned home and confessed the crime to his roommate. After his confession, he stripped down to his socks, entered the street, and began pacing and shouting.8 In terms of at-risk features, Eric Clark suffered from well-documented paranoid schizophrenia.7 On the night of the crime, he was in the midst of a psychotic episode and attempted to overcome his auditory hallucinations by turning up his radio volume, prompting police intervention. In his delusion, he perceived the police as aliens. Consequently, the issue before the Court was whether or not the defendant’s ‘‘mental illness, as a factual matter, made him unaware that he was shooting a police officer’’ because such a fact would negate the occurrence of a crime.9 His appeal to the Supreme Court was based on the interpretation of the insanity test and the exclusion of evidence of his mental illness on the issue of mens rea (required intent). He claimed insanity by reason of mental illness or defect for 2 purposes. First, he raised the affirmative defense of insanity that ‘‘at the time of the [crime, he] was afflicted with a mental disease or defect of such severity that he did not know the criminal act was wrong’’ and second, ‘‘to rebut the prosecution’s evidence of the requisite mens rea’’9 was an attempt to prove that Clark’s actions were not indicative of first-degree murder. The appeal was unsuccessful. The Clark case is one example of the legal system not fully understanding the dynamics
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of a diagnosis of schizophrenia. One author notes that juries ‘‘are even more frightened when defendants have mental illness and psychotic symptoms that they find horrible and/or unpredictable.’’10 In Clark’s case, the presence of ongoing psychosis of unspecified duration raises questions regarding the public’s perception of a person diagnosed with schizophrenia. The Patterson case is another excellent and unfortunate example of the disadvantages facing the mentally ill at trial. During the trial, Patterson’s lawyers raised the insanity defense. Claiming no motive for the killings, Patterson instead claimed that he was under the control of outside forces by way of implants and he was the center of conspiracies and in constant danger of poisoning.8 At Patterson’s competency hearing before the jury, defense counsel relied on the cross-examination of the State’s witnesses, a clinical psychologist and a forensic psychiatrist. Neither of these expert witnesses evaluated Patterson in person. Based on his records alone, they diagnosed Patterson with schizophrenia but proposed that Patterson had learned to fake psychosis. Both doctors believed Patterson was competent to stand trial. Patterson was convicted and later executed by the State of Texas. The low standard for competence, the effects of severe mental illness on the defendant’s courtroom behavior, and the tendency of the prosecutor to present a mental disorder as an aggravating factor instead of a mitigating factor exemplify the serious disadvantages a severely mentally ill defendant faces in capital proceedings.
Diagnosis independent from violence Clinical presentation and consequences Current diagnostic criteria require 6 months of symptoms, with at least 1 month of active symptoms and at least 2 of the characteristic symptoms.2 It should be noted that no single sign or symptom is indicative of the disorder. Several other conditions, including substance abuse and delirium, may mimic some of the signs and symptoms of schizophrenia and should be ruled out before a diagnosis of schizophrenia is determined.11 The most frequent initial symptoms of the disorder (fatigue and slowness, anxiety, concentration and thought disorders, and general overall slowing) may be overlooked or misdiagnosed. These signs demonstrate that cognitive function and social impairment may precede the initial diagnosis or first hospital admission.12 Although a robust
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discussion of the clinical presentation of schizophrenia is beyond the scope of this commentary, it is important to understand that the presence of a substantial lag time between symptom onset and diagnosis can negatively impact an individual’s overall prognosis. Reasons for this delay can be attributed to several causes, such as lack of insight,2,13 stigma associated with the illness, and the individual’s inability to know how to respond.13 Lack of insight often will delay diagnosis because the person is generally unaware that he/she is afflicted with a mental disorder,2 and there can be no expectation that medical attention will be sought. Stigma is also a treatment deterrent. Whereas a lack of insight impedes realization that help is needed, stigma prevents the person from wanting to seek medical treatment.14 Society’s stereotypical view and treatment of the mentally ill, namely that this population of individuals is violent, dangerous, and/or unpredictable, results in prejudice against the mentally ill when violence may be secondary to substance abuse.15,16 Consequently, a person who desires to seek treatment for a mental disorder will often forego medical attention in an effort to avoid diagnosis because this could lead to discrimination and isolation. Even if the person realizes treatment is necessary and overcomes the desire to avoid stigmatization, resources may be limited, particularly in underdeveloped areas.17 It was found that on average, at least 9 months may pass before help is sought, with some persons waiting up to 2 years.13 The time the individual goes without treatment is critical because significant brain changes occur even in the first year of the disorder.13,18 Hafner12 opined that as a disorder, schizophrenia was not static like mental retardation, nor did it exhibit a linear progression. Instead the disorder progresses rapidly with either a full remission or an episodic course, waxing and waning, characterized with residual symptoms. One study showed that even over a 10-year period, significant cognitive dysfunction, with a steady decline, was evident.19 As well as a steady cognitive decline, rapid deterioration associated with onset of the disorder has been demonstrated.20 Epidemiology and etiology Schizophrenia affects approximately 1% of the world’s population.11 This estimate may be underreported, however, because some persons with this disorder may not seek treatment. An accurate number of persons meeting criteria may be hard to identify.21 There is no formal medical test to
diagnose an individual with schizophrenia; there are, however, certain criteria that must be met to receive the diagnosis. The time of the first incidence of schizophrenia for both sexes is between the ages of 15 and 24 years, with females having a secondary peak between the ages of 55 and 64 years.22 This secondary peak may involve the role of estrogen in reducing sensitivity of certain receptors until menopause occurs.12 In one study, it was found that 77% of first-episode schizophrenia occurred before the age of 30 years, whereas 41% occurred before the age of 20 years.12 Schizophrenia does show a familial pattern. The risk to a person with a diagnosis in a first-degree relative is about 10 times greater than that of an individual in the general public.2,23 Although genes may play a role, it has yet to be determined exactly which genes are involved. Alterations in brain development are also associated with the disorder.24 This may present in the time frame to diagnosis. Specific changes in neurophysiology have been found. Diminishment of the hippocampal region as well as an overall decrease in brain mass have been shown. Functional and neurochemical changes may also be present in individuals with the disorder. Some may have alterations in the prefrontal lobe, a change usually more prominent in those with schizophrenia.25 Persons who undergo the largest decrease of gray matter in the brain are shown to have an increase in negative symptoms and are less likely to live on their own 5 years after diagnosis.18 Research indicates that genetic or familial patterns in schizophrenia are neither predictive nor contributive to violent behavior in patients with schizophrenia.26 Instead, factors such as social status and neurological defects that are often predictors of future violent behavior are indicators of these behaviors equally in populations of those diagnosed with and without schizophrenia. One study examined 928 individuals meeting diagnostic criteria for schizophrenia, schizoaffective disorder, and schizophreniform disorder in an effort to determine if there may be a neuropsychological basis for criminal activity later in life consistent with a diagnosis of schizophrenia.26 The study examined many aspects of the patients’ lives including birth complications, criminal records, and childhood information to ascertain a causal link.26 It was observed that the determinant factors for a risk of violent behavior were no different in the population of persons diagnosed with schizophrenia than that of the general population.26 It
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was not schizophrenia but rather global factors such as sociodemographic situations that lead to violence later in life. Environmental factors Several risk factors for the disorder have been found, including urban living and marijuana use. Urban living shows a higher incidence of schizophrenia compared with a rural setting,27 representing a casual risk of approximately 30%. One study showed that those with a baseline risk of psychosis, combined with an urban living environment, had a 2-fold increase in developing the disorder compared with those who only had one risk factor.13 Another risk may be substance abuse. Many persons with schizophrenia may have comorbid substance abuse. One substance shown to increase an individual’s risk for developing schizophrenia was marijuana, as a precipitant rather than a cause of schizophrenia.13 Environment appears to represent the most critical role in violence associated with schizophrenia. Although a patient diagnosed with schizophrenia is not inherently violent, it has been shown that a patient’s environment may be a contributory factor. The case of Eric Clark is an example. His hallucinations and paranoia triggered his violent behavior when his environment comported to the suggestions of his psychosis. It is known that the patient’s response to his or her environment compounds the diagnosis of schizophrenia and genetic or early environmental defects contribute to the social stresses that precipitate symptoms of schizophrenia.28 Although some research indicates that psychosis may be an indicator of violent tendencies, it is important to understand that it is the environmental effects on his or her psychosis that is a predictor of violent behavior.29 In other words, violence is a response between the patient and the patient’s environment, not a response between the patient and the disorder. The patient’s perception of his or her environment can potentially increase the psychosis, and change in the patient’s response to the environmental stimuli will manifest in violent or irrational behavior. An excellent example of this interplay between psychosis and environmental stimuli is the study of schizophrenia patients in the prison setting. It was often wondered why psychosis related to schizophrenia was more exaggerated in the prison setting and why those patients committed violent acts at a higher rate than the general population. Studies suggest that the prison environment is
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the contributory factor in precipitating violent responses from patients with schizophrenia. For example, prisons do not allow the patient to come and go freely, make choices, or escape to a ‘‘safe place’’ when psychosis is precipitated. The resulting response to psychosis by the patient is considered a violent outburst by the general population.30 For example, a patient who is paranoid may assault a prison guard because he or she believes the prison guard is ‘‘after’’ him or her and that the assault was justified as the only means to prevent harm.30 This is a rational response to the stimuli in the patient’s mind but is considered irrational and violent by the public. Violence related to diagnosis Violence is neither a sign nor a symptom of schizophrenia. A diagnosis of schizophrenia may increase the potential for conviction of a violent crime.31 When compared with a community-based population, persons with this diagnosis were approximately 3 times more likely to have been convicted of a violent crime (21.6% vs 7.8%).31 The overall prevalence of violent crime convictions averaged around 12%.15 One UK study found that 59% of persons diagnosed with schizophrenia who committed homicides were in the midst of a delusion and 56% reported a worsening of their delusions in the month preceding the murder.32 In addition, substance abuse was positively correlated with violent acts committed by persons with schizophrenia. In persons diagnosed with both schizophrenia and substance abuse, the risk of violent crime increased 4-fold.15 It should be noted that the rate of conviction and incarceration of mentally ill persons cannot be accurately determined. Although a conviction rate of 12% may not appear wholly significant, its significance goes beyond the number: the conviction rate for any given crime is not necessarily static. Consider assault as an example. The general population of middle-class white individuals charged with assault may experience a conviction rate of 5%, whereas the population of persons suffering from schizophrenia charged with the same crime may experience a conviction rate of 30%. The disparity is likely the result of the resources, finances, and experienced attorneys available to the defendant as well as the general population’s fear and stigmatization of the mentally ill.33 Scant attention has been given to the legal implications. Violence is a potential response to environmental stimuli that negatively provoke psychotic
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tendencies of the patient. Because violence is not inherent but rather a response to stimuli, it would follow that correct pharmacotherapy and other therapies would have the potential to decrease the occurrence of violent outbursts in patients with schizophrenia. Multiple roles for the pharmacist Mitigating potential violence Literature on rates of violence and persons with schizophrenia or mental illnesses has focused on collaborative efforts between general and forensic psychiatric services.34 Additional topics have included changes in available services, particularly over time,35 and utilization of the criminal justice.36 It is important for persons providing pharmaceutical care to persons diagnosed with schizophrenia to maintain a perspective on the historical funding shift for mental health policy as it applies to U.S. health care programs. Briefly, the period from 1965 to 1975 was characterized by the development of mental health programs facilitated by the Community Mental Health Centers Act (CMHCA), which provided federal support specifically to address mental health issues.37 These specific allocations were later changed in the early 1980s to nonspecific block grants.38 Changes in funding are also theorized to have negatively impacted service and program availability.39 Information on rates of violence during the CMHCA period was limited to hospital programs. More recent literature has focused on the characteristics of assaultive psychiatric patients. Schizophrenia is a recognized risk factor, particularly if the person is an older male. Also noted was substance abuse and mitigating factors of acute psychotic disorganization.40 Factors for consideration when health care professionals and organizations encounter severely mentally ill persons may include quality of life, stigma of mental illness, and pharmacotherapy options. The complex nature of the court system, especially that of criminal cases, poses further problems.41 Quality of life Because the main period of onset of schizophrenia occurs during major developmental periods of life, individuals with this diagnosis may show a marked lack of social achievement.12 This population is more likely to be unmarried compared with similar persons in the general public.22 One study showed that when compared with
the general community population, only 17% of males with schizophrenia were married compared with the 60% of the control group and only 32% of females with schizophrenia were married compared with 80% in the control group. This illustrates that personal relationships are hindered by a diagnosis of schizophrenia.12 The lower incidence of marriage in males may be a consequence to the earlier onset experienced by males, with an onset during the years when marriage is most common.22 Robust evidence has been published related to severe mental illness and violencedtopics that may not be addressed by mental health policies. Assaultive aggressive behavior, whether to self or others, is problematic for patients and facility staff and not limited to a particular region or setting.16,40,42-44 Approximately one-third of individuals diagnosed with schizophrenia attempt suicide more than once, with 5% of them succeeding.45 Risk for attempting suicide is highest during the postpsychotic phase.2 This is important to health care entities because inpatient hospitalization is common in persons with schizophrenia. Although the majority transition to outpatient status, only around 25% are not rehospitalized after 15 years.22 Many patients are able to live independently. When hospitalization does recur, inpatient status is much shorter, usually only for a few weeks.24,46 Readily available outpatient treatment plans and medications exist, and ‘‘inpatient treatment has become increasingly replaced by community-based facilities and teams and includes subacute hospitalization, day hospitalization, intensive (daily or evening) outpatient programs.’’46 In addition, funding for the public mental health system changed and inadequate community mental health resources resulted in the prisons and jails having an increased population of those with mental illnesses.43,47 Quality-of-life issues encompass medication effects. These may emerge during treatment. One observational post hoc analysis used information from patients to help determine the extent to which this impacted the individual. While addressing symptoms indicative of schizophrenia, recognition of treatment-emergent adverse effects when considering medication selection is of equal importance. The most frequently reported adverse effects findings were sexual dysfunction, extrapyramidal symptoms, and tardive dyskinesia.48 Pharmacotherapy Violence among persons with schizophrenia who were medication compliant was evaluated. In
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a study of 895 patients on stable pharmacotherapy, 5% demonstrated aggressive behavior in the week before assessment.49 Medication-compliant persons demonstrated a decreased incidence of suicide or attempted suicide. Furthermore, the addition of an antidepressant to an antipsychotic regimen was shown to lower the incidence of suicide even more.50 Historically, effective drug treatment for schizophrenia emerged in the 1950s, with the introduction of ‘‘neuroleptic’’ medications, chlorpromazine and reserpine. Although the medications helped diminish the signs and symptoms of schizophrenia, the high incidence of extrapyramidal side effects (EPSEs), such as the ability to initiate movements and marked restlessness, negatively impacted patient acceptance.11 Another untoward effect that can occur in older or first-generation antipsychotics (FGAs) is akathisia, a syndrome characterized by unpleasant sensations or feelings of inner restlessness. This may present as an inability to sit still or restlessness and irritability. In some cases, akathisia can lead to violent outbursts.51 Leong and Silva52 found several case reports and reports from larger studies. They opined that the lack of systematic reviews would limit inclusion of this potential medication-related effect to one aspect for consideration. Akathisia is more common with higher potency agents, such as haloperidol, compared with lower potency agents, such as chlorpromazine.51,53 The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) is a US-based research initiative to study the effectiveness of atypical or second-generation antipsychotics (SGAs) in individuals diagnosed with schizophrenia. Although SGAs demonstrated less EPSE compared with FGAs,11 increased rates of metabolic side effects such as diabetes, weight gain, and increased lipid levels11 were found. One study opined that these metabolic effects would eventually lead to an increased mortality among this population.27 It was found in both CATIE and UK-based Cost Utility of the Latest Antipsychotic Drugs in Schizophrenia Study (CUtLASS) that with the exception of clozapine, SGAs do not show more benefit than FGAs in patient compliance, effectiveness, and quality of life.54 Furthermore, the disheartening thing that CATIE was able to conclude was that none of the medications were able to fully alleviate psychosis, nor did they return cognitive function to baseline.55 It has been shown by numerous studies that patients prefer the benefits of SGAs compared with FGAs. In addition, with SGAs, fewer
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negative symptoms, better cognitive function, and improvement in affective symptoms are experienced.54 When cost of treatment is taken into consideration, the use of an FGA, if used properly and in modest dosing, will work as well as an SGA and shifted the focus to pharmacotherapy optimization and the patient.56-58 Pharmacist-specialized skill sets Pharmacists are in the unique position to integrate medication-related findings, an understanding of the impact of the diagnosis of schizophrenia, and epidemiologic data on this population. Pharmacists are often the first point of contact for patients with health inquiries. They are positioned to provide specific education to patients and family members as well as other disciplines regarding disease states and medications. This knowledge may be of particular interest to those in the legal system. Pharmacists can provide recommendations for questions on pharmacotherapy options, medication effects, and adherence concerns that may be raised. As the drug expert, the pharmacist can provide information on commonly reported side effects, class effects, and literature findings in addition to screening for potential drug-drug, drug-food, and drug-lab interactions. More systematic reviews and medication use evaluations may also help forensic agencies and persons in the legal system understand the complexities of a severe mental illness, such as schizophrenia, and how akathisia, as a medication-related effect, may impact the individual.
Conclusion A diagnosis of schizophrenia can be devastating, and it is a lifelong disorder. Although no one factor plays into development of the disorder, many variables may contribute. A predisposition to violence is not a recognized component for a diagnosis of schizophrenia; however, this perception may be commonplace in the general public. Given the complex and multifaceted nature of schizophrenia, there is a need to standardize or coordinate resources and legal interpretations for the disorder that are not punitive in nature. The goals should be to maintain the autonomy and dignity of the person. Involvement of the pharmacist can facilitate these goals by their knowledge of the disease state and impact of pharmacotherapy. Working in collaboration with the patient and family, the pharmacist can make a positive contribution.
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Stilwell et al. / Research in Social and Administrative Pharmacy 7 (2011) 421–429 33. Prince JD, Akincigil A, Bromet E. Incarceration rates of persons with first-admission psychosis. Psychiatr Serv 2007;58:1173–1180. 34. Hodgins S. The interface between general and forensic psychiatric services. Eur Psychiatry 2009;24:354–355. 35. Kramp P, Gabrielsen G. The organization of the psychiatric service and criminality committed by the mentally ill. Eur Psychiatry 2009;24:401–411. 36. Crocker AG, Cote G. Evolving systems of care: individuals found not criminally responsible on account of mental disorder in custody of civil and forensic psychiatric services. Eur Psychiatry 2009; 24:356–364. 37. Andrulis DP, Mazade NA. American mental health policy: changing directions in the 80s. Hosp Community Psychiatry 1983;34:601–606. 38. Sharfstein SS. Medicaid cutbacks and block grants: crisis or opportunity for community mental health? Am J Psychiatry 1982;139:466–470. 39. Rothbard AB, Kuno E, Hadley TR, Dogin J. Psychiatric service utilization and cost for persons with schizophrenia in a Medicaid managed care program. J Behav Health Serv Res 2004;31:1–12. 40. Flannery RB Jr, Farley E, Tierney T, Walker AP. Characteristics of Assaultive Psychiatric Patients: 20-Year Analysis of the Assaultive Staff Action Program (ASAP). Psychiatr Q; 2010. 41. Graham MH. Evidence: Text Rules, Illustrations and Problems. Louisville, CO: National Institute for Trial Advocacy; 1983. 42. Elsayed YA, Al-Zahrani M, Rashad MM. Characteristics of mentally ill offenders from 100 psychiatric court reports. Ann Gen Psychiatry 2010;9:4. 43. Hodgins S, Alderton J, Cree A, Aboud A, Mak T. Aggressive behaviour, victimization and crime among severely mentally ill patients requiring hospitalisation. Br J Psychiatry 2007;191:343–350. 44. Steinert T, Wiebe C, Gebhardt RP. Aggressive behavior against self and others among first-admission patients with schizophrenia. Psychiatr Serv 1999;50: 85–90. 45. Tandon R, Nasrallah HA, Keshavan MS. Schizophrenia, ‘‘just the facts’’ 4. Clinical features and conceptualization. Schizophr Res 2009;110:1–23.
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46. King LJ. A brief history of psychiatry: millennia past and presentdpart II. Ann Clin Psychiatry 1999;11: 47–54. 47. Gilligan J. The last mental hospital. Psychiatr Q 2001;72:45–61. 48. Adrianzen C, Arango-Davila C, Araujo DM, et al. Relative association of treatment-emergent adverse events with quality of life of patients with schizophrenia: post hoc analysis from a 3-year observational study. Hum Psychopharmacol 2010;25: 439–447. 49. Bobes J, Fillat O, Arango C. Violence among schizophrenia out-patients compliant with medication: prevalence and associated factors. Acta Psychiatr Scand 2009;119:218–225. 50. Haukka J, Tiihonen J, Harkanen T, Lonnqvist J. Association between medication and risk of suicide, attempted suicide and death in nationwide cohort of suicidal patients with schizophrenia. Pharmacoepidemiol Drug Saf 2008;17:686–696. 51. Galynker II, Nazarian D. Akathisia as violence. J Clin Psychiatry 1997;58:31–32. 52. Leong GB, Silva JA. Neuroleptic-induced akathisia and violence: a review. J Forensic Sci 2003; 48:187–189. 53. Herrera JN, Sramek JJ, Costa JF, Roy S, Heh CW, Nguyen BN. High potency neuroleptics and violence in schizophrenics. J Nerv Ment Dis 1988;176: 558–561. 54. Naber D, Lambert M. The CATIE and CUtLASS studies in schizophrenia: results and implications for clinicians. CNS Drugs 2009;23:649–659. 55. Revisiting the CATIE schizophrenia study. Although questions remain, some clinical guidance has emerged. Harv Ment Health Lett 2008;25:1–3. 56. Lewis S, Lieberman J. CATIE and CUtLASS: can we handle the truth? Br J Psychiatry 2008;192: 161–163. 57. Parks JJ, Radke AQ, Tandon R. Impact of the CATIE findings on state mental health policy. Psychiatr Serv 2008;59:534–536. 58. Duckworth K, Fitzpatrick MJ. NAMI perspective on CATIE: policy and research implications. Psychiatr Serv 2008;59:537–539.
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Commentary
Violence among persons diagnosed with schizophrenia: How pharmacists can help Emily N. Stilwell, Pharm.D. Candidatea, Sarah E. Yates, J.D. Candidateb, Nancy C. Brahm, Pharm.D., M.S.a,* a
Department of Pharmacy Practice, Clinical and Administrative Sciences, 4502 E. 41st Street, Tulsa, OK 74135-2512, USA b The University of Tulsa College of Law, 3120 East 4th Place, Tulsa, OK 74104, USA
Abstract Violence among those diagnosed with schizophrenia has been reported but is not a diagnostic component of the disorder. The position of the courts regarding fulfillment of the requisite intent to commit violent acts has not been extensively reported. This article discusses the impact of a diagnosis of schizophrenia in an individual and how the pharmacist can help integrate information into the health care system. The recent Supreme Court case of Clark versus Arizona and the older case of Patterson versus Cockrell are discussed with respect to the concept of intent (to commit the act) and the implications this has on an individual in the midst of a psychotic episode. Quality of life, the perception of the stigma associated with a diagnosis of schizophrenia, and pharmacotherapy are briefly discussed. The origin of schizophrenia is multifactorial. Persons with schizophrenia are not innately violent, but alteration in perception may precipitate aggressive acts. Given the complex and diverse nature of schizophrenia and the fact that even with successful pharmacological treatment residual symptoms may still be present, there is a need to provide information to health care practitioners and the court. Ó 2011 Elsevier Inc. All rights reserved. Keywords: Schizophrenia; Violence; Constitutional; Mens rea
Introduction Based on Greek roots schizo (split) and phrene (mind), the term ‘‘schizophrenia’’ is approaching the 100-year point. Swiss psychiatrist Eugene Bleuler first used the term in 1911 and separated the symptoms into ‘‘positive’’ or ‘‘negative’’ categories.1 The etiology is still largely unknown; therefore, scientists can only base their classifications on the observation of symptom occurrence. The
most recent criteria based on the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision) define schizophrenia as a disorder occurring for the time of at least 6 months, with a minimum of 1 month of active symptoms that can include positive and negative symptoms2 and problems in cognition (Table 1). In addition, subsets of the disorder have been identified: paranoid, disorganized, catatonic, residual, and undifferentiated. For the purposes of this
* Corresponding author. University of Oklahoma College of Pharmacy, 4502 E. 41st Street, 2H17, Tulsa, OK 741352512, USA. Tel.: þ1 918 660 3579; fax: þ1 918 660 3009. E-mail address: [email protected] (N.C. Brahm). 1551-7411/$ - see front matter Ó 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.sapharm.2010.11.002
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Table 1 Examples of schizophrenia-associated symptoms Positive
Negative
Cognitive
Delusions
Lack of emotional expressiveness (affective flattening) Poverty of speech (alogia) Loss of joy (anhedonia) Avolition Inability to speak Lack of initiative
Inhibition
Hallucinations Suspiciousness Disorganized behavior Disorganized speech (schizophasiaa)
Impaired working memory
a
Schizophasia: moving quickly from topic to topic, without any logical progression. The words used may also have no meaning or association with one another. Data from American Psychiatric Association2 and Schultz et al.11
article, schizophrenia will be discussed broadly with differentiation as needed. Determining whether or not violence is an inherent component in patients with schizophrenia is critical. Currently, modern society still views persons with schizophrenia as violent per se, and the stigma of schizophrenia for patients is profound. Such a stereotype precipitates a fear of those with schizophrenia and an assumption of violent behavior. However, violence is not included either in the formal diagnostic criteria or as a characteristic of one of the subsets nor has the disorder itself been conclusively linked to violent behavior. This article is an effort to illuminate the likely and unlikely connections between schizophrenia and violent behavior.
Schizophrenia: violence assumptions Stigma of schizophrenia The mention of mental illness throughout history and among certain cultures is met with a negative connotation. Beliefs about persons with mental illness range from believing they are dangerous to believing they somehow contributed to their own illness. Persons with schizophrenia are most likely the population that experiences the majority of this stigma. It has been found that beliefs regarding ‘‘social inappropriateness’’ and ‘‘unpredictability and dangerousness’’ are indicators for how individuals in the general public behave toward persons with schizophrenia.3 Persons with schizophrenia are not usually violent; they are more likely to harm themselves than another individual. Suicide attempts and completions are very common.4 Hewitt4 suggests that it is the burden of having to live with a chronic mental disorder that leads these individuals to self-harm and suicide.
One study showed that 66% of individuals surveyed in the health care field hold attitudes that persons with schizophrenia are ‘‘dangerous.’’5 These beliefs only compound the monumental problem persons with schizophrenia already facedthe chronic nature of their illness. Discriminatory effects almost constitute a ‘‘second illness,’’ which manifests in several ways from interpersonal relationships to social roles.6 Stigma associated with schizophrenia may result in patients waiting longer to seek treatment. A recent study focusing on stigma and discrimination toward persons diagnosed with schizophrenia and their families found that most negative experiences resulted from health care settings and family.6 The study also found that individuals in this cohort tended to keep to themselves. The researchers hypothesized that this was a coping strategy used to protect themselves from facing rejection in social settings.6 However, in family settings, they felt that they were overprotected. Comparatively in health care settings, these individuals felt their concerns were not heard or taken into consideration. The discrimination and stigma faced by these persons in the health care field is a reason for concern because this is the avenue in which these individuals use to gain integration into society and seek help for their illness.5 Because it has been shown that stigma and discrimination occur in health care settings where it is presumed providers have a better knowledge base than the general public, this bias may carry over into the legal system. Societal application of stigma The perception of violence as a component of schizophrenia was brought to the public’s attention by a recent Supreme Court case, Clark versus Arizona. This case involved an adolescent
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diagnosed with schizophrenia who murdered a police officer acting in the line of duty. Eric Clark, aged 17 years at that time, believed the police officer was a hostile alien trying to kill him. Clark was actively psychotic with both hallucinations and delusions. The symptoms had been persistent for some time. Clark also believed the entire town in which he lived was populated by aliens. The hallucinations affected Clark to the extent that he had his room at his parents’ home set up with security alarms and would only eat food that was sealed in a package, in fear of being poisoned.7 In an attempt to drown out the voices he heard, Clark had turned the volume of his radio up to its maximum volume. The noise level prompted a call to the police who were sent to Clark’s home to remedy the situation. Another example is the case of Patterson versus Cockrell. In this case, Kelsey Patterson suffered from well-documented paranoid schizophrenia and multiple encounters with police and the legal system. In 2004, Patterson, without motive, shot and killed 2 individuals. After the double murder, he made no effort to conceal the crimes; instead he returned home and confessed the crime to his roommate. After his confession, he stripped down to his socks, entered the street, and began pacing and shouting.8 In terms of at-risk features, Eric Clark suffered from well-documented paranoid schizophrenia.7 On the night of the crime, he was in the midst of a psychotic episode and attempted to overcome his auditory hallucinations by turning up his radio volume, prompting police intervention. In his delusion, he perceived the police as aliens. Consequently, the issue before the Court was whether or not the defendant’s ‘‘mental illness, as a factual matter, made him unaware that he was shooting a police officer’’ because such a fact would negate the occurrence of a crime.9 His appeal to the Supreme Court was based on the interpretation of the insanity test and the exclusion of evidence of his mental illness on the issue of mens rea (required intent). He claimed insanity by reason of mental illness or defect for 2 purposes. First, he raised the affirmative defense of insanity that ‘‘at the time of the [crime, he] was afflicted with a mental disease or defect of such severity that he did not know the criminal act was wrong’’ and second, ‘‘to rebut the prosecution’s evidence of the requisite mens rea’’9 was an attempt to prove that Clark’s actions were not indicative of first-degree murder. The appeal was unsuccessful. The Clark case is one example of the legal system not fully understanding the dynamics
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of a diagnosis of schizophrenia. One author notes that juries ‘‘are even more frightened when defendants have mental illness and psychotic symptoms that they find horrible and/or unpredictable.’’10 In Clark’s case, the presence of ongoing psychosis of unspecified duration raises questions regarding the public’s perception of a person diagnosed with schizophrenia. The Patterson case is another excellent and unfortunate example of the disadvantages facing the mentally ill at trial. During the trial, Patterson’s lawyers raised the insanity defense. Claiming no motive for the killings, Patterson instead claimed that he was under the control of outside forces by way of implants and he was the center of conspiracies and in constant danger of poisoning.8 At Patterson’s competency hearing before the jury, defense counsel relied on the cross-examination of the State’s witnesses, a clinical psychologist and a forensic psychiatrist. Neither of these expert witnesses evaluated Patterson in person. Based on his records alone, they diagnosed Patterson with schizophrenia but proposed that Patterson had learned to fake psychosis. Both doctors believed Patterson was competent to stand trial. Patterson was convicted and later executed by the State of Texas. The low standard for competence, the effects of severe mental illness on the defendant’s courtroom behavior, and the tendency of the prosecutor to present a mental disorder as an aggravating factor instead of a mitigating factor exemplify the serious disadvantages a severely mentally ill defendant faces in capital proceedings.
Diagnosis independent from violence Clinical presentation and consequences Current diagnostic criteria require 6 months of symptoms, with at least 1 month of active symptoms and at least 2 of the characteristic symptoms.2 It should be noted that no single sign or symptom is indicative of the disorder. Several other conditions, including substance abuse and delirium, may mimic some of the signs and symptoms of schizophrenia and should be ruled out before a diagnosis of schizophrenia is determined.11 The most frequent initial symptoms of the disorder (fatigue and slowness, anxiety, concentration and thought disorders, and general overall slowing) may be overlooked or misdiagnosed. These signs demonstrate that cognitive function and social impairment may precede the initial diagnosis or first hospital admission.12 Although a robust
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discussion of the clinical presentation of schizophrenia is beyond the scope of this commentary, it is important to understand that the presence of a substantial lag time between symptom onset and diagnosis can negatively impact an individual’s overall prognosis. Reasons for this delay can be attributed to several causes, such as lack of insight,2,13 stigma associated with the illness, and the individual’s inability to know how to respond.13 Lack of insight often will delay diagnosis because the person is generally unaware that he/she is afflicted with a mental disorder,2 and there can be no expectation that medical attention will be sought. Stigma is also a treatment deterrent. Whereas a lack of insight impedes realization that help is needed, stigma prevents the person from wanting to seek medical treatment.14 Society’s stereotypical view and treatment of the mentally ill, namely that this population of individuals is violent, dangerous, and/or unpredictable, results in prejudice against the mentally ill when violence may be secondary to substance abuse.15,16 Consequently, a person who desires to seek treatment for a mental disorder will often forego medical attention in an effort to avoid diagnosis because this could lead to discrimination and isolation. Even if the person realizes treatment is necessary and overcomes the desire to avoid stigmatization, resources may be limited, particularly in underdeveloped areas.17 It was found that on average, at least 9 months may pass before help is sought, with some persons waiting up to 2 years.13 The time the individual goes without treatment is critical because significant brain changes occur even in the first year of the disorder.13,18 Hafner12 opined that as a disorder, schizophrenia was not static like mental retardation, nor did it exhibit a linear progression. Instead the disorder progresses rapidly with either a full remission or an episodic course, waxing and waning, characterized with residual symptoms. One study showed that even over a 10-year period, significant cognitive dysfunction, with a steady decline, was evident.19 As well as a steady cognitive decline, rapid deterioration associated with onset of the disorder has been demonstrated.20 Epidemiology and etiology Schizophrenia affects approximately 1% of the world’s population.11 This estimate may be underreported, however, because some persons with this disorder may not seek treatment. An accurate number of persons meeting criteria may be hard to identify.21 There is no formal medical test to
diagnose an individual with schizophrenia; there are, however, certain criteria that must be met to receive the diagnosis. The time of the first incidence of schizophrenia for both sexes is between the ages of 15 and 24 years, with females having a secondary peak between the ages of 55 and 64 years.22 This secondary peak may involve the role of estrogen in reducing sensitivity of certain receptors until menopause occurs.12 In one study, it was found that 77% of first-episode schizophrenia occurred before the age of 30 years, whereas 41% occurred before the age of 20 years.12 Schizophrenia does show a familial pattern. The risk to a person with a diagnosis in a first-degree relative is about 10 times greater than that of an individual in the general public.2,23 Although genes may play a role, it has yet to be determined exactly which genes are involved. Alterations in brain development are also associated with the disorder.24 This may present in the time frame to diagnosis. Specific changes in neurophysiology have been found. Diminishment of the hippocampal region as well as an overall decrease in brain mass have been shown. Functional and neurochemical changes may also be present in individuals with the disorder. Some may have alterations in the prefrontal lobe, a change usually more prominent in those with schizophrenia.25 Persons who undergo the largest decrease of gray matter in the brain are shown to have an increase in negative symptoms and are less likely to live on their own 5 years after diagnosis.18 Research indicates that genetic or familial patterns in schizophrenia are neither predictive nor contributive to violent behavior in patients with schizophrenia.26 Instead, factors such as social status and neurological defects that are often predictors of future violent behavior are indicators of these behaviors equally in populations of those diagnosed with and without schizophrenia. One study examined 928 individuals meeting diagnostic criteria for schizophrenia, schizoaffective disorder, and schizophreniform disorder in an effort to determine if there may be a neuropsychological basis for criminal activity later in life consistent with a diagnosis of schizophrenia.26 The study examined many aspects of the patients’ lives including birth complications, criminal records, and childhood information to ascertain a causal link.26 It was observed that the determinant factors for a risk of violent behavior were no different in the population of persons diagnosed with schizophrenia than that of the general population.26 It
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was not schizophrenia but rather global factors such as sociodemographic situations that lead to violence later in life. Environmental factors Several risk factors for the disorder have been found, including urban living and marijuana use. Urban living shows a higher incidence of schizophrenia compared with a rural setting,27 representing a casual risk of approximately 30%. One study showed that those with a baseline risk of psychosis, combined with an urban living environment, had a 2-fold increase in developing the disorder compared with those who only had one risk factor.13 Another risk may be substance abuse. Many persons with schizophrenia may have comorbid substance abuse. One substance shown to increase an individual’s risk for developing schizophrenia was marijuana, as a precipitant rather than a cause of schizophrenia.13 Environment appears to represent the most critical role in violence associated with schizophrenia. Although a patient diagnosed with schizophrenia is not inherently violent, it has been shown that a patient’s environment may be a contributory factor. The case of Eric Clark is an example. His hallucinations and paranoia triggered his violent behavior when his environment comported to the suggestions of his psychosis. It is known that the patient’s response to his or her environment compounds the diagnosis of schizophrenia and genetic or early environmental defects contribute to the social stresses that precipitate symptoms of schizophrenia.28 Although some research indicates that psychosis may be an indicator of violent tendencies, it is important to understand that it is the environmental effects on his or her psychosis that is a predictor of violent behavior.29 In other words, violence is a response between the patient and the patient’s environment, not a response between the patient and the disorder. The patient’s perception of his or her environment can potentially increase the psychosis, and change in the patient’s response to the environmental stimuli will manifest in violent or irrational behavior. An excellent example of this interplay between psychosis and environmental stimuli is the study of schizophrenia patients in the prison setting. It was often wondered why psychosis related to schizophrenia was more exaggerated in the prison setting and why those patients committed violent acts at a higher rate than the general population. Studies suggest that the prison environment is
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the contributory factor in precipitating violent responses from patients with schizophrenia. For example, prisons do not allow the patient to come and go freely, make choices, or escape to a ‘‘safe place’’ when psychosis is precipitated. The resulting response to psychosis by the patient is considered a violent outburst by the general population.30 For example, a patient who is paranoid may assault a prison guard because he or she believes the prison guard is ‘‘after’’ him or her and that the assault was justified as the only means to prevent harm.30 This is a rational response to the stimuli in the patient’s mind but is considered irrational and violent by the public. Violence related to diagnosis Violence is neither a sign nor a symptom of schizophrenia. A diagnosis of schizophrenia may increase the potential for conviction of a violent crime.31 When compared with a community-based population, persons with this diagnosis were approximately 3 times more likely to have been convicted of a violent crime (21.6% vs 7.8%).31 The overall prevalence of violent crime convictions averaged around 12%.15 One UK study found that 59% of persons diagnosed with schizophrenia who committed homicides were in the midst of a delusion and 56% reported a worsening of their delusions in the month preceding the murder.32 In addition, substance abuse was positively correlated with violent acts committed by persons with schizophrenia. In persons diagnosed with both schizophrenia and substance abuse, the risk of violent crime increased 4-fold.15 It should be noted that the rate of conviction and incarceration of mentally ill persons cannot be accurately determined. Although a conviction rate of 12% may not appear wholly significant, its significance goes beyond the number: the conviction rate for any given crime is not necessarily static. Consider assault as an example. The general population of middle-class white individuals charged with assault may experience a conviction rate of 5%, whereas the population of persons suffering from schizophrenia charged with the same crime may experience a conviction rate of 30%. The disparity is likely the result of the resources, finances, and experienced attorneys available to the defendant as well as the general population’s fear and stigmatization of the mentally ill.33 Scant attention has been given to the legal implications. Violence is a potential response to environmental stimuli that negatively provoke psychotic
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tendencies of the patient. Because violence is not inherent but rather a response to stimuli, it would follow that correct pharmacotherapy and other therapies would have the potential to decrease the occurrence of violent outbursts in patients with schizophrenia. Multiple roles for the pharmacist Mitigating potential violence Literature on rates of violence and persons with schizophrenia or mental illnesses has focused on collaborative efforts between general and forensic psychiatric services.34 Additional topics have included changes in available services, particularly over time,35 and utilization of the criminal justice.36 It is important for persons providing pharmaceutical care to persons diagnosed with schizophrenia to maintain a perspective on the historical funding shift for mental health policy as it applies to U.S. health care programs. Briefly, the period from 1965 to 1975 was characterized by the development of mental health programs facilitated by the Community Mental Health Centers Act (CMHCA), which provided federal support specifically to address mental health issues.37 These specific allocations were later changed in the early 1980s to nonspecific block grants.38 Changes in funding are also theorized to have negatively impacted service and program availability.39 Information on rates of violence during the CMHCA period was limited to hospital programs. More recent literature has focused on the characteristics of assaultive psychiatric patients. Schizophrenia is a recognized risk factor, particularly if the person is an older male. Also noted was substance abuse and mitigating factors of acute psychotic disorganization.40 Factors for consideration when health care professionals and organizations encounter severely mentally ill persons may include quality of life, stigma of mental illness, and pharmacotherapy options. The complex nature of the court system, especially that of criminal cases, poses further problems.41 Quality of life Because the main period of onset of schizophrenia occurs during major developmental periods of life, individuals with this diagnosis may show a marked lack of social achievement.12 This population is more likely to be unmarried compared with similar persons in the general public.22 One study showed that when compared with
the general community population, only 17% of males with schizophrenia were married compared with the 60% of the control group and only 32% of females with schizophrenia were married compared with 80% in the control group. This illustrates that personal relationships are hindered by a diagnosis of schizophrenia.12 The lower incidence of marriage in males may be a consequence to the earlier onset experienced by males, with an onset during the years when marriage is most common.22 Robust evidence has been published related to severe mental illness and violencedtopics that may not be addressed by mental health policies. Assaultive aggressive behavior, whether to self or others, is problematic for patients and facility staff and not limited to a particular region or setting.16,40,42-44 Approximately one-third of individuals diagnosed with schizophrenia attempt suicide more than once, with 5% of them succeeding.45 Risk for attempting suicide is highest during the postpsychotic phase.2 This is important to health care entities because inpatient hospitalization is common in persons with schizophrenia. Although the majority transition to outpatient status, only around 25% are not rehospitalized after 15 years.22 Many patients are able to live independently. When hospitalization does recur, inpatient status is much shorter, usually only for a few weeks.24,46 Readily available outpatient treatment plans and medications exist, and ‘‘inpatient treatment has become increasingly replaced by community-based facilities and teams and includes subacute hospitalization, day hospitalization, intensive (daily or evening) outpatient programs.’’46 In addition, funding for the public mental health system changed and inadequate community mental health resources resulted in the prisons and jails having an increased population of those with mental illnesses.43,47 Quality-of-life issues encompass medication effects. These may emerge during treatment. One observational post hoc analysis used information from patients to help determine the extent to which this impacted the individual. While addressing symptoms indicative of schizophrenia, recognition of treatment-emergent adverse effects when considering medication selection is of equal importance. The most frequently reported adverse effects findings were sexual dysfunction, extrapyramidal symptoms, and tardive dyskinesia.48 Pharmacotherapy Violence among persons with schizophrenia who were medication compliant was evaluated. In
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a study of 895 patients on stable pharmacotherapy, 5% demonstrated aggressive behavior in the week before assessment.49 Medication-compliant persons demonstrated a decreased incidence of suicide or attempted suicide. Furthermore, the addition of an antidepressant to an antipsychotic regimen was shown to lower the incidence of suicide even more.50 Historically, effective drug treatment for schizophrenia emerged in the 1950s, with the introduction of ‘‘neuroleptic’’ medications, chlorpromazine and reserpine. Although the medications helped diminish the signs and symptoms of schizophrenia, the high incidence of extrapyramidal side effects (EPSEs), such as the ability to initiate movements and marked restlessness, negatively impacted patient acceptance.11 Another untoward effect that can occur in older or first-generation antipsychotics (FGAs) is akathisia, a syndrome characterized by unpleasant sensations or feelings of inner restlessness. This may present as an inability to sit still or restlessness and irritability. In some cases, akathisia can lead to violent outbursts.51 Leong and Silva52 found several case reports and reports from larger studies. They opined that the lack of systematic reviews would limit inclusion of this potential medication-related effect to one aspect for consideration. Akathisia is more common with higher potency agents, such as haloperidol, compared with lower potency agents, such as chlorpromazine.51,53 The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) is a US-based research initiative to study the effectiveness of atypical or second-generation antipsychotics (SGAs) in individuals diagnosed with schizophrenia. Although SGAs demonstrated less EPSE compared with FGAs,11 increased rates of metabolic side effects such as diabetes, weight gain, and increased lipid levels11 were found. One study opined that these metabolic effects would eventually lead to an increased mortality among this population.27 It was found in both CATIE and UK-based Cost Utility of the Latest Antipsychotic Drugs in Schizophrenia Study (CUtLASS) that with the exception of clozapine, SGAs do not show more benefit than FGAs in patient compliance, effectiveness, and quality of life.54 Furthermore, the disheartening thing that CATIE was able to conclude was that none of the medications were able to fully alleviate psychosis, nor did they return cognitive function to baseline.55 It has been shown by numerous studies that patients prefer the benefits of SGAs compared with FGAs. In addition, with SGAs, fewer
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negative symptoms, better cognitive function, and improvement in affective symptoms are experienced.54 When cost of treatment is taken into consideration, the use of an FGA, if used properly and in modest dosing, will work as well as an SGA and shifted the focus to pharmacotherapy optimization and the patient.56-58 Pharmacist-specialized skill sets Pharmacists are in the unique position to integrate medication-related findings, an understanding of the impact of the diagnosis of schizophrenia, and epidemiologic data on this population. Pharmacists are often the first point of contact for patients with health inquiries. They are positioned to provide specific education to patients and family members as well as other disciplines regarding disease states and medications. This knowledge may be of particular interest to those in the legal system. Pharmacists can provide recommendations for questions on pharmacotherapy options, medication effects, and adherence concerns that may be raised. As the drug expert, the pharmacist can provide information on commonly reported side effects, class effects, and literature findings in addition to screening for potential drug-drug, drug-food, and drug-lab interactions. More systematic reviews and medication use evaluations may also help forensic agencies and persons in the legal system understand the complexities of a severe mental illness, such as schizophrenia, and how akathisia, as a medication-related effect, may impact the individual.
Conclusion A diagnosis of schizophrenia can be devastating, and it is a lifelong disorder. Although no one factor plays into development of the disorder, many variables may contribute. A predisposition to violence is not a recognized component for a diagnosis of schizophrenia; however, this perception may be commonplace in the general public. Given the complex and multifaceted nature of schizophrenia, there is a need to standardize or coordinate resources and legal interpretations for the disorder that are not punitive in nature. The goals should be to maintain the autonomy and dignity of the person. Involvement of the pharmacist can facilitate these goals by their knowledge of the disease state and impact of pharmacotherapy. Working in collaboration with the patient and family, the pharmacist can make a positive contribution.
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