Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Intensity vs prevalence
- Dryden Badenoch (9 November 2001)
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Violence and Mental Illness
- Kelwyn Williams (9 November 2001)
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violence-mental illness-psychopharmacological treatment
- Detlef Degner (14 November 2001)
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The wrong intervention and the wrong patients
- Tom Clark (19 November 2001)
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Do not seek and you will not find
- Larry Rifkin (22 November 2001)
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Case management, violence and the Care Programme Approach
- John M Eagles (29 November 2001)
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Clozapine in the Management of Violence within the Setting of Severe Mental Illness
- Ernest H Bennie (17 December 2001)
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Dryden Badenoch, Clinical Psychologist Tayside Area Clinical Psychology Department
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The finding that a quantitative change in intervention does not yield a qualitative change in outcome seem unremarkable. My own experience is that, where there is a risk of violence, interventions tend to yield a reduction in frequency and intensity, not a "cure" (ie: total absence of the problem). "A positive score on any of these sources indicated a positive score for assault. The frequency or seriousness of assault was not recorded." I appreciate that frequency and seriousness of assault would be much more difficult to measure reliably, but the failure to do so should have been mentioned in the "strengths and weaknesses" of the study. |
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Kelwyn Williams, Consultant Psychiatrist Gloucester
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Neither this article nor the editorial by Steinert mention the prime predictor of violence - male sex. |
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Detlef Degner Germany D-37075 Gottingen Department of Psychiatry,University of Göttingen
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There is no consideration of the relevance of psychopharmacological strategies.The reasons for violence are complex,the management of this problem must be discussed with consideration of the biopsychosocial context. |
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Tom Clark, clinical research fellow in forensic psychiatry University of Birmingham, Reaside Clinic, Birmingham, B45 9BE
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Walsh et al described a study designed to establish whether intensive case management reduces violence in patients with severe mental illness (1). Unfortunately they evaluated the wrong intervention in the wrong group of patients. The “intensive case management” studied was one in which case managers had the same level of training and skill as in the control group. The authors themselves state that assertive community treatment has not been designed to reduce the risk of physical assault. There is a psychiatric subspecialty which does aim to do this. Forensic psychiatric services depend on staff who are specifically trained and have the experience and expertise to identify risk when present and manage it appropriately with the support of a similarly orientated multidisciplinary clinical team. A high rate of patient contact is essential to, though only a part of, such a service. Prior identification of patients who may pose a risk of violence is essential to the future management of that risk. Research that fails to target high-risk individuals is of little benefit. In the current study more than 1 in 5 eligible patients were not included. It might be expected that a history or high risk of violence would be a factor associated with failure to randomise. The research by Swanson et al. quoted in the current study (2), examined the use of enforced community treatment in patients previously identified as high risk. The call by the authors for research “evaluating the effectiveness of combining specific clinical interventions within … a protective legal framework” is welcome. This need not wait for further developments in mental health legislation. The community rehabilitation order with additional requirements of psychiatric treatment provides such a framework. In the 53 years since its introduction (as the psychiatric probation order) it has been maligned by psychiatrists and ignored by researchers. It is commonly applied inappropriately and managed inadequately (3). The failure of this study to demonstrate a reduction in the rate of physical violence must be interpreted with caution. Future research needs to concentrate on more important issues. How can patients who may present a risk of harm to others be identified more accurately? How can specifically designed services be effectively targeted at those in need of them? Are current medical and legal options being used efficiently, can their use be improved and does experience help to inform future developments? The answers to these questions demand clarification before the introduction of further legal provisions and their associated infringements of civil liberty. References 1. Walsh E, Gilvarry C, Samele C, Harvey K, Manley C, Tyrer P et al. Reducing violence in severe mental illness: randomised controlled trial of intensive case management compared with standard care. British Medical Journal 2001; 323:1093 2. Swanson J, Swartz M, Borum R, Hiday V, Wagner H, Burns B. Involuntary out-patient commitment and reduction of violent behaviour in persons with severe mental illness British Journal of Psychiatry 2000; 176:324-331 3. Clark T, Kenney-Herbert J, Baker J, Humphreys M. Psychiatric probation orders: failed provision or future panacea Medicine Science and the Law (in press) |
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Larry Rifkin, Consultant Psychiatrist and Hon Senior Lecturer Maudsley Hospital, London SE5 8AF
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Walsh et al's article is already being editorialised and qouted as evidence that more intensive work with SMI patients does not help to reduce violence. This is an unfortunate and sadly predictable response which does not stand up to a critical examination of the study. The study was NOT designed to examine wether violence could be reduced by more intensive case management. It was primarily a comparison of the effectivness of low vs standard keyworker caseloads in the management of psychotic patients on the CPA. A large range of outcomes were measured which have been and will be the subject of other publications. The management of and reduction of violent incidents was not a specific aim of the study. It is also not possible to determine wether violence was in fact reduced or not. The frequency and severity of violent incidents was not measured and all that can be concluded is that more intensive generic key working does not reduce the chance of someone being assaultative on at least one occasion over a two year period. This may mask the possibility that the severity and frequency of violence is reduced even by such a non -specific intervention. The underlying but unstated premise of the study is that the violent incidents occur as a result of mental illness and that more intensive treatment will therefore reduce violence. However the reasons for the assaults and the relationship between mental state and the assaults is not examined. There is also no control group. It may be the case that a age, gender and social class matched control group would be equally or more likely to have assaulted someone in the past 2 years. Clearly future studies examining this issue need to have the reduction of violence as a specific aim of the study. Such interventions should examine the effect of targeted interventions on violent behaviour with a reduction in the frequency and/or severity of violence as the outcome measure. This study should not be used to argue the need for community treatment orders etc as it does not address the issues relevant to that debate. |
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John M Eagles, Consultant Psychiatrist Royal Cornhill Hospital, Cornhill Road, Aberdeen, AB25 2ZH
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Editor Walsh et al1 found that patients with psychotic illnesses who received intensive case management were no less likely to commit physical assault than were patients receiving standard case management over a two year period. The tenor of their paper, and that of the related editorial2, is that the rate (around 22%) of widely defined assault reflects increased violence among the mentally ill and they quote Steadman et al3 in support of this contention. In fact, Steadman et al3 found in Pittsburgh that for discharged patients who did not have symptoms of substance misuse violence was no more common than among community controls. Without utilising a control population, predominantly of young men living in socially disadvantaged circumstances, it is invalid to suggest that the Walsh et al1 findings demonstrate a link between psychotic illness and violence. As Leff4 recently concluded, "careful analysis of the figures for violent crime has revealed that people with mental illness are not especially prone to violent acts". However, coupled with the same group's earlier paper5 showing that intensive case management does nothing to reduce rates of self-harm, the findings are of definite clinical significance. Care Programme Approach (CPA), as they point out1, with its many similarities to intensive case management, was introduced to address the "fragmentation" between services which existed (certainly in London) and was deemed to be contributing to violence and self-harm among the mentally ill. CPA is seen by many psychiatrists as time-consuming and bureaucratic. Given that it never had an evidence base and its credibility has been thoroughly undermined by the two Walsh et al studies1,5, perhaps it should now be phased out. Yours faithfully DR. JOHN M. EAGLES Consultant Psychiatrist References 1. Walsh E, Gilvarry C, Samele C, Harvey K, Manley C, Tyrer P et al. Reducing violence in severe mental illness: randomised controlled trial of intensive case management compared with standard care. BMJ 2001;323:1093-6. 2. Steinert T. Reducing violence in severe mental illness. BMJ 2001;323:1080-1. 3. Steadman H J, Mulvey E P, Monahan J, Robbins P C, Appelbaum P S, Grisso T et al. Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighborhoods. Arch Gen Psychiatry 1998;55:393-401. 4. Leff J. Why is care in the community perceived as a failure? BJ Psychiatry 2001;179:381-3. 5. Walsh E, Harvey K, White I, Higgitt A, Fraser J, Murray R. Suicidal behaviour in psychosis: prevalence and predictors from a randomised controlled trial of case management. BJ Psychiatry 2001;178:255-60. |
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Ernest H Bennie, Consultant Forensic Psychiatrist Ailsa Hospital, Ayr, KA6 6AB
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Clozapine in the Management of Violence within the Setting of Severe Mental Illness Two years ago Ayrshire & Arran Health Board set up it’s Community Forensic Mental Health Service. From that time until present approximately 189 clients with problem behaviour and a history of violence have been referred with the objective of supporting and maintaining them in the community. In the light of reports by Steinart1 and Walsh2 in the BMJ of 10th November 2001, an optimistic objective. Twelve had failed to respond to conventional measures and have been offered treatment with Clozapine. To date, 3 female and 9 male patients, in whom violent or disruptive behaviour was a management challenge have now been treated successfully with Clozapine for up to 12 months and two cases are briefly described. Firstly. A 31 year old single male served ten years for Culpable Homicide, re-offended on release from Prison. Consequently he was transferred to hospital from prison and Clozapine was commenced. His behaviour and mental state progressively stabilised and following his return home, he co-operated with his Community Forensic Charge Nurse. There have been no further violent episodes and he has not re-offended. A 40 year old single female had her children taken into care following a twenty year history of violence associated with severe self- harm and alcohol abuse. She was imprisoned following an attack on her Social Worker and required transfer to hospital where Clozapine Therapy was commenced. Now she is living in her home, co-operating in her supervision and compliant with her Clozapine therapy. Generally, she is settled and there has been no recurrence of assaultative behaviour or violent episodes. She is being considered as being suitable for access to her children. We would support the view that even with intensive management, a number of our patients failed to make progress and continued to re-offend and impose a heavy burden of care on the psychiatric services. There have been anecdotal accounts in the literature of Clozapine being useful in the management of violence3 within the settings of psychotic illnesses. Our experience confirmed this observation. Patients who agreed to treatment with Clozapine showed a rapid reduction in all aspects of violent and disruptive behaviour. We have noted that patients with challenging behaviour are difficult to assess especially in the emergency room situation or by the on-call Psychiatrist. They can be dismissed as being untreatable or not suffering from mental illness. Some have been turned away from psychiatric facilities with tragic results4. Traditionally, Psychiatrists have been educated to diagnose schizophrenia on the basis of the presence of positive or negative symptoms, behavioural signs being regarded as non- specific. Our observation that Clozapine produces a rapid remission in behavioural signs would lead us to put forward the view that within the setting of the psychotic process, certain behavioural signs would be diagnostic rather than non-specific. Behavioural signs including hostile and violent acts have been found to be a very frequent presentation of severe mental illness. It would be useful for the study of Walsh2 to be repeated comparing Clozapine to conventional drug treatment in a double blind fashion, in the community management of the severely mentally ill who have a history of violence. Ernest H Bennie
Paul M Gilius
References: 1. Steinert, T. Reducing violence in severe mental illness. Centre of Psychiatry, University of Ulm, D88214 Weissenau, Germany. BMJ 2001;323:1080-1 2. Walsh, E. et al. Reducing violence in severe mental illness: randomised controlled trial of intensive case management compared with standard care. BMJ 2001;323:1093-6 3. Chengappa, K.N.R et al. Clozapine reduces severe self-mutilation and aggression in psychotic patients with borderline personality disorder. J Clin Psychiatry, 1999, 60, 477-84 4. Press Reports Editorial note
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