Date Published: April 16, 2019
Publisher: Public Library of Science
Author(s): Stefano Barlati, Alberto Stefana, Francesco Bartoli, Giorgio Bianconi, Viola Bulgari, Valentina Candini, Giuseppe Carrà, Cesare Cavalera, Massimo Clerici, Marta Cricelli, Maria Teresa Ferla, Clarissa Ferrari, Laura Iozzino, Ambra Macis, Antonio Vita, Giovanni de Girolamo, Kenji Hashimoto.
The management of mentally ill offenders in the community is one of the great challenges imposed on community psychiatry.
The aim of this study was to analyze the association between sociodemographic, clinical, and psychosocial factors and violent behavior in a sample of outpatients with severe mental disorders.
This was a prospective cohort study with a baseline cross-sectional design used to provide a detailed analysis of patients’ profiles, followed by a longitudinal design to measure aggressive and violent behavior during a 1-year follow-up. Patients with severe mental disorders, with or without a history of violence, were enrolled in four Italian Departments of Mental Health and underwent a comprehensive multidimensional assessment.
The sample included 247 outpatients, for a total of 126 cases and 121 controls. Compared to controls, patients with a history of violence had a greater frequency of lifetime domestic violence, a greater lifetime propensity to misuse substances, and a higher number of compulsory admissions. The forthnightly monitoring during the 1-year follow-up did show statistically significant differences in aggressive and violent behavior rates between the two groups. Verbal aggression was significantly associated with aggression against objects and physical aggression. Moreover, outpatients with an history of violence showed statistically significant higher MOAS scores compared to both residential patients with an history of violence, assessed in the first wave of this project, and all controls.
Patients with a history of violence had specific characteristics and showed a greater occurrence of additional community violence during a 1-year observation period. Our results may assist clinicians in implementing standardized methods of patient assessment and violence monitoring in outpatient mental health services and may prompt improved collaboration between different community services.
Several studies have investigated the association between severe mental disorders (SMDs) and violence, many of which focused on psychiatric patients admitted to or discharged from acute inpatient facilities,  Residential Facilities (RFs) , or Forensic Mental Hospitals (FMHs) ; other studies have assessed the risk of violence among outpatients in treatment at mental health services [4,5]. All these studies have identified several variables that may increase the risk of violence, including male gender, a diagnosis of schizophrenia, substance use disorders, and a lifetime history of violence . However, only a few studies prospectively assessed the frequency of aggressive and violent behavior among patients in different treatment settings, such as outpatient care and RFs: the latter in many countries have replaced mental hospitals for long-term care [7,8].
A recent Italian law (81/2014) enacted a significant reorganization of the forensic system, with the closure of the six FMHs, the opening of new small-scale high-security units, and a consequent transfer of many patients with SMD who had offended, or are at risk of offending, to ordinary DMHs (including RFs managed by these services). This change has prompted a deeper investigation into the risk of aggressive and violent behavior among patients in treatment at DMHs. To our knowledge, this is the first Italian study, and one of very few internationally, to use a large set of standardized multidimensional evaluation tools and to prospectively examine the frequency and severity of aggressive and violent behavior in outpatients with SMDs.
Our data show that outpatients with a history of violence are more aggressive than patients with no lifetime violent behavior. The management of mentally ill offenders in the community is one of the great challenges imposed on community psychiatry. Indeed, more intensive care, as found in RFs, where treatment is granted and prevention of significant substance use disorders is avoided, is associated with a substantial decrease in the frequency and severity of aggressive and violent behavior even among people with a history of violence.