Friends of the Forensic Science Club, this week we present the paper “Could Expanding and Investing in First-Episode Psychosis Services Prevent Aggressive Behaviour and Violent Crime?” by Hodgins, S. (2022), in which the author carries out a revision about previous literature about the treatments that people with schizophrenia have received to improve their aggressive behavior. 

Schizophrenia is a very complex and difficult to treat mental illness, which causes suffering to those who suffer it in the first person, but also their loved ones.

Some people who develop or present it, engage in aggressive and sometimes criminal behavior.

Most of these individuals suffer a first episode of psychosis that marks a before and after, but before this episode they usually show behaviors with a certain level of aggressiveness.

However, the needed services to treat the first episodes of psychosis have improved the care of these people, by their early interventions in the course of the illness. This would also help with violent behavior, since some people with schizophrenia have a history of violent behavior and even antisocial behavior since childhood, so they will need urgent treatment. 

Even so, the reality is that many care services for the first episode of psychosis do not treat or evaluate aggressive behavior, so patients manifest them inside and outside psychiatric services.

On many occasions, when this aggressive behavior explodes and someone gets hurt, the perpetrator is charged with a violent crime. Some of these people are judged not criminally responsible due to the mental disorder they suffer, and are sent to forensic psychiatric hospitals. Others are found guilty and sentenced to prison in a conventional center.

In other words, the human costs of the inability to identify and treat these patients when they first come to clinical services are enormous.

Existing literature indicates that first episode psychotic care services have the potential to prevent many manifestations of these aggressive behaviors and, therefore, violent crimes by people with schizophrenia.

This would reduce the human suffering of patients and victims, as well as the costs of police, courts, prisons and other social care resources, also helping to reduce the stigma against people with mental illnesses.

There is evidence that confirms that people with schizophrenia are more likely than their peers of the same age and gender to engage in aggressive behavior (which, in turn, can lead to criminal prosecution). They are at higher risk of being convicted of non-violent and violent crimes, and especially of being convicted of homicide. However, mental health services for people with schizophrenia do not assess or treat aggressive behaviors.

A meta-analysis found that 35% of people who contacted care services for their first episode of psychosis had previously suffered at least one aggression.

For example, a study with more than 200 people treated by these services, carried out in the United Kingdom, found that a third of men and 10% of women were convicted or found not guilty for mental illness in at least one violent crime . That is, it appears that most patients with schizophrenia who display aggressive behavior are indeed at increased risk of offending.

In general, among the people that present a first episode of psychosis and suffer from schizophrenia, there are two groups: one of them are people who have a long history of violent behavior problems that have sometimes ended up turning into crimes, and on the other hand, there are the people who recently manifest this type of aggressive behavior.

Another significant piece of information is provided by a study carried out in Canada, which reports that the majority of people declared not criminally responsible due to a mental disorder, between 2000 and 2005, were men with a diagnosis of schizophrenia who had committed a violent crime.

A meta-analysis showed that 29-38% of the patients seen in first-episode psychosis clinics used cannabis regularly. Another meta-analysis found that, among people with severe mental illness, the risk of violent attitudes increased between two and five times with cannabis use. This suggests that these people may also suffer from an addiction disorder.

On the other hand, adults with schizophrenia show higher levels of victimization than their neighbors, even after being aware of their own criminality, and are also more at risk of being victims of homicide.

It has been shown that when treatment is applied to these patients, which in addition to being focused on schizophrenia also focuses on violent behavior, their mental health improves and aggressive episodes are reduced.

Therefore, all the available evidence suggests that identifying and treating this behavior, in addition to psychosis, would reduce the suffering of patients, and the secondary human and economic costs. In addition, it would promote the safety of patients and their loved ones and help them with their independence and autonomy.

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