Psychiatric Clinic, 1st Faculty of Medicine, Charles University, Prague, Czech Republic, and School of Public Health, University of California, Berkeley, USA
T VESEL
, PhD
University of California, Berkeley, USA
OVÁ, MD
Psychiatric Clinic, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
Correspondence: Dr Jan Vevera, Psychiatric Clinic, 1st Faculty of Medicine, Charles University, Ke Karlovu 11, Prague 120 00, Czech Republic. E-mail: janvevera{at}centrum.cz
Declaration of interest None. Funding detailed in Acknowledgements.
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ABSTRACT |
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Aims To determine the prevalence of violence among those with schizophrenia in samples from 1949, 1969, 1989 and 2000 in Prague (Czech Republic) and to examine trends in this behaviour.
Method Records from 404 patients meeting DSMIV criteria for schizophrenia were screened for violence (defined as 3 points on the Modified Overt Aggression Scale) from the first observed psychotic symptoms until the time of latest available information.
Results Logistic regression revealed a marginally significant increase in violence only in the 2000 cohort. Overall, violence was associated with schizophreniain 41.8% of men and 32.7% of women, with no association between substance misuse and violence.
Conclusions The violence rate found in our sample is expected to remain stable over time under stable conditions. Substance misuse is not the leading cause of violence among those with schizophrenia.
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INTRODUCTION |
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METHOD |
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There were no major organisational changes during the study period. Deinstitutionalisation policies were not applied during the 1960s but the number of inhabitants in the catchment area decreased by about half (53%) between 1950 and 1970. There were 174 500 inhabitants in Prague 2 in 1950, and 92 200, 61 800 and 51 000 in the years 1970, 1991 and 2001, respectively (Czech Statistical Office, 2003a). Commercial building in the former residential blocks occurred across the area and was unrelated to the characteristics of the patients living there, so we consider the process to be random. The population decrease is consistent with the fact that between 1949 and 1969 the number of hospitalised patients with schizophrenia decreased to about half the number in 1949.
Evaluation methods
Records from all 572 patients were reviewed by an experienced psychiatrist
(J.V.). Only those patients (n=404) meeting the DSMIV criteria
for schizophrenia (295.13, 295.6 and 295.9) were included in the study.
The review procedures were identical for all samples. All charts available
were located and reviewed. For patients who had moved, updated addresses were
obtained from the Central Register of the Czech Population, and new records
were obtained from the psychiatric facility in the new catchment areas
whenever the patient was rehospitalised.
Information on violence of patients in the community and hospital during the study period was acquired from medical records. We recorded all aggressive attacks since the first observed psychotic symptoms. The duration of observation was defined as the time between the first observed psychotic symptoms and the time of the last available information. Aggressive behaviour was evaluated using the Modified Overt Aggression Scale (MOAS; Kay et al, 1988). The MOAS measures four categories of aggression: (1) verbal aggression, (2) physical aggression against self, (3) physical aggression against objects and (4) physical aggression against other people. The most severe aggressive event within each category is multiplied by its designated weight factor and then summed to yield a total aggression score. Patients were considered to be violent if they expressed overt and intentional physically aggressive behaviour against another person or a verbal threat with an accompanying weapon, with a total aggression score of 3 or more points on the MOAS. We selected this relatively high threshold on the MOAS to avoid underreporting of violence, because verbal violence or minor attacks with minimal consequences are less likely to be reported (Volavka, 2002). Information on substance misuse or dependency was acquired from medical records. That information was part of the diagnostic interview throughout the study period. Underreporting of substance misuse is common, however we typically have information covering a period of 1520 years from six admissions and discharges records (Table 1), which should make our data more reliable. Detailed evaluations of violent incidents were not available for the patients from the 1949 and 1969 cohorts; a typical note was: physically aggressive over the last 3 days or repeated heteroaggression in anamnesis. This statement shows that the patient reached the threshold (3 points on the MOAS) but does not provide information on the target and intensity of attacks. In the 1989 and 2000 cohorts the aggressors or their psychiatrists were interviewed in every single case and the target was specified.
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Patients who committed one or more assaults in one 2-week period were classified as transiently violent. Patients who committed at least two assaults in at least two different 2-week periods were classified as persistently violent.
Statistical analysis
Logistic regression was used to investigate trends in the prevalence of
violence among patients with schizophrenia. Presence or absence of violence
served as a binary variable in the logistic regression; cohort was entered
both as an unordered categorical variable using dummy variables and as an
ordered variable (1=1949, 2=1969, 3=1989, 4=2000) to test for trends in
violence. We performed analyses both unadjusted and adjusted for both length
of observation (by simply including a linear term of the number of years a
patient was followed from the first observed psychotic symptoms until the time
of latest available information) and for gender. Observation time was adjusted
for because more recent cohorts would typically have less observation time and
this will confound any associations with cohort and trends in violence. We
also used logistic regression to examine the association of violence with both
gender and substance misuse, in each case adjusting for length of
observation.
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RESULTS |
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Trends in prevalence of violence
Using unadjusted logistic regression, there was no significant linear trend
in the prevalence of violence among the cohort members between 1949 and 2000
(OR=1.08, 95% CI 0.911.29). However when adjusting for length of
observation and gender, there was a marginally significant increasing trend in
the probability of violence over the four cohorts (OR=1.21, 95% CI
0.991.47). The change in significance was because the more recent
cohorts had less observation time.
Repeating the adjusted analyses on the categorical 1949 cohort (see Table 2), we found a significant difference only when comparing the 2000 and 1949 cohorts (OR=2.01, 95% CI 1.073.75). Although the trend in violence appeared more pronounced among women than men, the difference in trends was not statistically significant (test of interaction P=0.37).
Victims of violence 1989 and 2000 cohorts only
Only one person was hospitalised as a result of an attack by a patient from
the 1989 and 2000 cohorts. There was one death: a patient threw a female from
the window of his apartment on the first occasion he met her. This is the only
murder reported as a result of an attack by any of the patients studied
(19492000). Victims of all assaults by the 1989 and 2000 cohorts are
described in Table 4.
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Prevalence of violence and substance misuse
There was a history of comorbid substance misuse disorders (mostly alcohol
305.0, 303.9, with only two cases of sedative and anxiolytic drug misuse
(304.1 and 305.4) and one case of trihexyphenidyl misuse) in 1.8%, 7.2% and
7.1% of patients from the 1949, 1969 and 1989 cohorts respectively. In the
2000 cohort the prevalence of substance misuse was 19.4% (14 patients). Only
4.2% of patients were diagnosed with alcohol misuse. One female patient (1.4%)
misused sedatives and 13.8% of patients misused illicit drugs. Cannabis misuse
was found in 5.6% of patients, amphetamine misuse in 1.4% and polysubstance
misuse in 6.9%.
When data from all four cohorts were analysed, neither the unadjusted nor adjusted (for categorical cohort and gender) associations between substance misuse and violence were statistically significant (adjusted OR=0.78, 95% CI 0.341.82). The small numbers of violent offenders did not allow us to perform meaningful statistical analysis for any of the cohorts independently.
Duration of hospitalisation
There were no differences in the duration of the first hospitalisation and
the cumulative duration of all hospitalisations when adjusted for observation
years. Eighty-three patients from the 1949 cohort never received
antipsychotics. These had markedly longer (P<0.001) total duration
of hospitalisation (9.23 years; s.d.=11.54) than patients who received
antipsychotics (1.74 years; s.d.=4.04).
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DISCUSSION |
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In the USA fragmentation of care is thought to be responsible for an increasing rate of violence (Hogan, 2003). Similarly we hypothesised that fragmentation of care in the Czech Republic, which occurred as a consequence of the unsuccessful transformation of health services (Zacek, 1997), as well as gaps in providing integrated care (Vevera, 2004), were probably responsible for increases in violence in 2000.
Violence among patients with schizophrenia
The overall prevalence of violence was 42% for men and 33% for women. Only
a weak association was found between gender and violence which is similar to
other recent studies (Robbins et
al, 2003).
Victims of violent assaults 1989 and 2000 cohorts only
Analysis of victims of violent assaults shows that family members were
involved in half of the assaults committed by male as well as female
offenders. Strangers were attacked in 17% of assaults. This evidence further
supports previous findings (Steadman
et al, 1998; Milton
et al, 2001) that families are the major victims.
Unfortunately we do not have data on victimisation among our patients with
schizophrenia, but there is evidence that psychiatric patients are more likely
to end up as victims rather than perpetrators of violent acts
(Walsh et al,
2003).
Duration of hospitalisation
Introduction of new treatments, particularly antipsychotic medication in
the mid-1950s, allowed the cure and amelioration of psychotic symptoms. Hence
the duration of hospitalisation was markedly longer (9.23 years) for those
patients from the 1949 cohort who never received antipsychotic pharmacotherapy
compared with those who used antipsychotics (1.74 years).
There were no differences in the duration of the first hospitalisation and the cumulative duration of all hospitalisations when adjusted for observation years.
Substance misuse and schizophrenia
The comorbidity of schizophrenia and substance misuse from 1949 to 1989 in
our study ranged from 2 to 7% and was markedly lower than in studies from the
USA and Western Europe, where lifetime rates of any misuse have ranged between
40 and 60% (Regier et al,
1990; Cantor-Graae et
al, 2001). The lowest prevalence of alcohol misuse found in
the 1949 cohort was probably influenced by the lower availability of alcohol
during the Second World War, but the low prevalence of alcohol misuse was
consistent throughout the study. We hypothesise that no problems with
homelessness, good access to free or government-provided healthcare and a high
level of supervision by state authorities have protected patients from
deteriorating into substance misuse. Paradoxically patients with schizophrenia
could benefit from the high level of control typical of a totalitarian state.
After the fall of the communist regime in 1989, the prevalence of alcohol
misuse remained stable but the misuse of illicit drugs increased
significantly. In our 2000 sample we found a rate of substance misuse of
19.4%. Since only 4.2% of patients misuse alcohol the availability of illicit
street drugs was responsible for this increase. Alcohol misuse was markedly
lower than in the general population, in which 18.5% of men and 3.5% of women
reported drinking problems (measured as 2 or more points on the CAGE
questionnaire) according to a study conducted in 19992000
(Bobak et al, 2004).
By tradition the Czech Republic has a high alcohol consumption (9.9 litres of
pure alcohol in the year 2000) with 160 litres of beer consumed per citizen in
2000, which make it first in beer consumption
(Czech Statistical Office,
2003b). Data from 1999 show that 17% of adults reported
lifetime drug misuse (Csemy et al,
2002). These data show that those with schizophrenia do not have
higher rates of substance misuse than the general population.
Substance misuse and violence
Surprisingly no association was found between substance misuse and
violence. Data from the MacArthur Study
(Steadman et al,
1998) indicate that substance misuse is responsible for the
increased rate of violence among psychiatric patients. Misuse of legal drugs
(alcohol) robustly correlated with violence; however, occasional use of
alcohol appeared to be a protective factor compared with abstinent patients
with schizophrenia (Volavka et
al, 1997). It could be hypothesised that those drinking
occasionally have higher levels of social skills, which make them less likely
to be violent. A study conducted in Canada, Germany, Finland and Sweden also
did not find an increased risk of violence among those with schizophrenia and
substance misuse (Hodgins et al,
2003). A recent Australian study also cast doubt on the role of
substance misuse alone in accounting for the higher rates of offending among
those with schizophrenia (Wallace et
al, 2004).
Together these findings suggest that in a stable healthcare system substance misuse is not the leading cause of violence among patients with schizophrenia. Preventing patients from misusing substances is not sufficient to reduce the prevalence of violence. Strategies aimed at disordered impulse control and psychopathic characteristics, which now seem to be the leading causes of violence among those with schizophrenia (Nolan et al, 1999, 2003), could decrease violence. Psychotherapeutic techniques, such as cognitivebehavioural treatment, which target anger-regulatory mechanisms are already showing promising results in patients with post-traumatic stress disorder, psychoses and developmental disabilities (Chemtob et al, 1997; Novaco & Taylor, 2004). Treatment with atypical antipsychotic medications, which appear to have ameliorative effects on cognitive symptoms among patients with schizophrenia (Bilder et al, 2002), may help to reduce confusion-related assaults.
Given the low number of those with associated substance misuse, we hypothesise that the aggressive behaviour in our cohorts is primarily linked to the nature of the underlying psychopathological condition, namely disordered impulse control, psychopathy and psychotic symptoms. This rate of aggression would be expected to remain stable over time with stable conditions, for example a patients relatively stable socioeconomic level, a stable healthcare system and limited access to street drugs.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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Received for publication July 27, 2004. Revision received February 8, 2005. Accepted for publication February 12, 2005.
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