Mental Illness and Serious Harm to Others - University of Liverpool

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NHS National Programme on Forensic Mental Health Research and Development rate on cessation (e.g. Kane, 1996). A substantial minority of patients benefit little from conventional antipsychotic drugs (Schulz and Buckley, 1995), but many of these may be helped by the so-called atypical antipsychotics - clozapine, and the medications mostly new to the 1990s. Do they offer any advantage in limiting violence in the context of these illnesses? A number of reviews have highlighted evidence which suggests that effective medication may confer advantage with respect to violence in the acute situation (Royal College of Psychiatrists, 1998) and more generally (Taylor and Buckley, 2000; Tiihonen and Swartz, 2000; Volavka and Citrome, 2000). Naturalistic studies in the English high security hospitals of the impact of clozapine on improvement of disorder and reduction in violence (Dalal et al, 1999) and on shortening stay for the longer-term group with schizophrenia (Swinton and Haddock, 2000) are encouraging, although for a variety of reasons, many patients who might benefit appear to be unsuitable for this drug (Swinton and Ahmed,1999). There is some suggestion that it may be possible to contain 'disruptive’, and perhaps violent behaviour, among patients with psychosis, even when the symptoms of the illness are not improved (e.g. Kane and Marder, 1993; Marder et al, 1997). However, these studies focus exclusively on the presence or absence of symptoms. The drugs may still be exerting an effect through the illness, rather than having some independent or perhaps specifically anti-aggressive effect. In this context, it is likely to be important also to measure the impact of symptoms (Taylor et al, 1994), for example the extent to which a given symptom makes the patient frightened or depressed, and the extent to which the medication can at least relieve the effect. There are at least four important problems with the treatment data to date: ❑ Violence has a low base rate, even within groups of people who have been violent or threaten it, so attributes like 'hostility’ and 'aggression’ are taken as surrogates for violence, without evidence that it is valid to do so. ❑ The data are overly dependent on uncontrolled and non-randomised studies. It is not at all clear that measures that are effective for inpatients translate to life in the wider community. ❑ The kind of drug combinations preferred by many in practice for people who have been seriously violent in the context of their mental illness - commonly a conventional depot neuroleptic combined with an atypical antipsychotic drug taken by mouth - have not been adequately tested, particularly for the long term. ❑ Medication may be a necessary treatment for most people with psychosis in this context, but it is rarely, if ever, sufficient. Psychological approaches to reduce specific symptoms or their impact are promising (e.g. Garety et al, 1994; Tarrier et al, 1998), but the findings as yet not directly tested in this field. Growing acknowledgement of the fact that violence is an interactional problem, and that even where one party may be a clear instigator, reactions can diffuse or escalate the situation, leads to the possibility that specific interventions with family, other carers or staff may be as helpful to the patient as more directly patient-oriented work. So far, the emphasis for staff is on various aspects of training (e.g. Phillips and Rudestam, 1995; Taylor and Schanda, 2000), but the concept of high expressed emotion (EE) may prove to be as applicable to staff working in long-term relationships with patients as to the close 11
NHS National Programme on Forensic Mental Health Research and Development relatives of the patients (Moore, Ball and Kuipers, 1992). Indeed, in this last study, aggressive behaviour on the part of the patient was one of the significant correlates of criticism and high staff EE. If EE can develop in this way, then a testable hypothesis is that staff supervision that incorporates strategies for recognising and reducing this may be effective first in maintaining therapeutic relationships and, as a result, in enhancing the detection or management of any deterioration and risk. 3.6 Management strategies effective for people with mental illness and problems with violence The tasks of managing people in the relatively controlled environment of the inpatient setting and the largely uncontrolled world outside are very different. The environments pose very different benefits and stresses. Those in close proximity to relations they perceive as intrusive or threatening, for example, may be helped by removal to a more neutral environment. By contrast, those who live their lives away from others, while perhaps needing inpatient care in their own interests, may feel unduly challenged by the proximity of the many people who fill a hospital inpatient unit. Such variation is rarely acknowledged in research. There seems to be something of a common assumption in the literature, not always explicit, which is reflected in clinical practice, that similar strategies - at least for risk assessment - will apply. Tardiff et al (1997) are alone in having clearly demonstrated, for a cohort of people admitted to an acute psychiatric inpatient unit, an association between pre-admission and post-discharge violence, but none whatsoever between inpatient violence and post-discharge violence. Follow-up periods were, however, short. Nevertheless, the existing literature does fall naturally into two categories in this area - the management or prevention of imminent violence in the inpatient setting, and outpatient work. The difficulties of designing and implementing work for the inpatient setting are considered, together with evidence for the effectiveness of a range of preventive strategies here, in one multiply peer-reviewed paper (Taylor and Schanda, 2000). Management of imminent violence is the focus of another systematic review (Royal College of Psychiatrists, 1998). The latter is forced back onto basing its recommendations largely on consensus rather than evidence, because of the scarcity of evidence. In the former review, we were impressed by some relatively easily remediable gaps, such as evidence on a role (or not) for substance misuse in inpatient violence, the value of specific treatment for pertinent disorder, and the importance of qualities in nursing staff communication. The priority question-setting exercise by the National Programme on Forensic Mental Health R&D revealed no questions from those surveyed on professional development and no current research in this area, and yet the small literature to date would suggest that staff can be trained or assisted to prevent, and perhaps manage, inpatient violence more effectively. This would seem an area ripe for further development and research. Moving to the outpatient setting, there is, in the UK, a small collection of naturalistic studies of people discharged from one of the special hospitals (and therefore after presumed recovery or improvement from a mental disorder perceived as relevant to dangerous behaviour). These consistently show that those in the groups under compulsory supervision are less likely to re-offend - violently or otherwise - than those 12
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Mental Illness and Serious Harm to Others - University of Liverpool

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