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Rapid Responses: Rapid Responses published:
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Lesson for individual psychological treatment
- Chris D Burford (28 March 2004)
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Secular trend and loss of impulse control...
- James M. Howard (1 April 2004)
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Isn't Alcohol abuse a psychiatric problem
- Maneesh Gupta (3 April 2004)
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Chris D Burford, Consultant Psychiatrist St Ann's Hospital, St Ann's Road, London N15 3TH
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This careful study has important implications for reducing both homicides of strangers and homicides of known victims too. The system of public enquiries set up after the report on the care of Christopher Clunis for all homicides by people with mental illness, may inappropriately increase public alarm and stigma about mental illness. To reduce stigma it is not enough correctly to argue that suicide is a far greater problem than homicide in mental illness. What perhaps captures the public imagination with headlines after each public homicide enquiry is the mysterious and occasionally unpredictable nature of psychosis. Much remains mysterious but progress is being made and the public should be reassured that serious efforts are under way. Clearly a serious untoward investigation needs to take place in every case of homicide, but if I read this study correctly the implications are that it will be far more productive nationally to target the individual psychological and social needs of the patient and their family than to implement systems of greater public control which would appear to treat patients as a public health hazard lacking minds of their own. In the population studied over 3 years there would appear to have been only 8 people with a diagnosis of schizophrenia who killed a stranger who had not attended mental health services in the previous week. By comparison there were 64 people with a diagnosis of schizophrenia who killed someone known to them. In terms of implementing public health measures to reduce the overall figure it would be more productive to ensure detailed audit to check that the individual psychological needs of all these people with a diagnosis of schizophrenia, are met routinely. Especially compelling is the argument that screening for family interventions, long known to be important in the recovery from psychosis, must be routine, since this study shows victims known to the perpetrator remain almost 80% of all victims. If the figures for affective disorder include affective psychoses, this gives even more weight to apply such good policies in health care to the wider set of people with psychosis overall, since in any case schizophrenia is recognised to be a heterogeneous diagnosis. Concerning the other diagnostic categories, again one of the clinical implications would appear to be to offer more individual psychological treatment. Irritability and anger are symptoms that stretch across diagnostic categories as they are non-specific. They may therefore be overlooked by traditional mental health services based on diagnosis. There would appear to be good arguments for screening all patients with mental illness for significant unresolved problems of this nature and offering them a course in anger management, which in my clinical experience is often heard as a dignified and constructive proposals even by patients who do not have insight into other aspects of their problems. It is welcome the study is funded by the National Institute for Clinical Evidence. It provides compelling evidence that its guidelines on good practice in the individual treatment of schizophrenia, probably extended to all psychotic syndromes, should now be backed with a serious national survey to identify how well they are being implemented, and what are the obstacles. Dr Chris Burford Consultant Psychiatrist Competing interests: Committee Member of UK chapter of ISPS, the International Society for the Psychological Treatments of the Schizophrenias and other psychoses. www.isps.org |
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James M. Howard, independent biologist 1037 North Woolsey Avenue, Fayetteville, Arkansas 72701-2046, U.S.A.
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It is my hypothesis that the "secular trend," the increase in size and earlier puberty occurring in our children, actually is an increase in the percentage of individuals of higher testosterone within our populations. This increase will increase the occurrence and identification of the characteristics of these individuals. One of the characteristics I attribute to this group is increased impulsivity. I suggest the increased homicide rate results from this increased lack of impulse control. This should be highest in young males. (The cause of this population increase probably results from the effects of maternal testosterone on the brains of their fetuses. Soon, young women should increase their percentages within the various characteristics produced by this population change.) Increased alcohol and drug abuse is another characteristic I attribute to this phenomenon. This further decreases impulse control. Competing interests: None declared |
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Maneesh Gupta, Consultant Psychiatrist, New Delhi, India. 201001
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The article concludes that most convictions of homicide were of individuals with or under the influence of Alcohol or other drugs. Is it not important that mental health services that target substance abuse and dependence be strengthened to reduce both the number of substance abusers and thereby the number of homicides? It is a mistake to consider only psychosis as a major psychiatric illness, and to be complacent in finding that most homicides were by people who did not have psychosis. Competing interests: None declared |
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