Letter to the Editor Long-term hemodialysis improved and ...
Letter to the editor
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References 1. Bechdolf A, Knost B, Kuntermann C et al. A randomized comparison of group cognitive-behavioural therapy and group psychoeducation in patients with schizophrenia. Acta Psychiatr Scand 2004;110:21–28. 2. Lewis S, Tarrier N, Haddock G et al. Randomised con- trolled trial of cognitive-behavioural therapy in early schi- zophrenia: acute-phase outcomes. Br J Psychiatry 2002;181(suppl. 43):91–97. 3. Kuipers E, Garety P, Fowler D, Dunn G et al. London-East Anglia randomised controlled trial of cognitive-behavioural therapy for psychosis, I: effects of the treatment phase. Br J Psychiatry 1997;171:319–327. DOI: 10.1111/j.1600-0447.2005.00680.x To the editor: We read the article ÔHomicide and major mental disorders: a 25-year studyÕ by Schanda et al. (1) with interest. We find it likely that schizophrenia and delusional disorder would lead to serious violence and murder with delusions being the promin- ent driving force. This would agree with the previously cited literature (2). It was interesting to note that personality disorder was not investigated in relation to murder. This would be expected as personality disorder (psychopathy) is associated with high risk of violence and recidivism. We would like to know why the authors did not find this given it is such a strong predictor of risk (3, 4). M. Malik, E. Silva Ashworth Hospital Parkbourn, Maghull L31 1HW UK References 1. Schanda H, Knecht G, Schreinzer D, Stompe TH, Ortwein- Swoboda G, Waldoer TH. Homicides and major mental disorders: a 25-year study. Acta Psychiatr Scand 2004;110:98–107. 2. Doctor R. Psychodynamic lessons in risk assessment and management. Adv Psychiatr Treat 2004;10:267–276. 3. Steadman H, Mulvey E, Monahan J, Robbins P, Applebaum P, Grisso T, Roth L, Silver E. Violence from people discharged from acute psychiatric in patient and by others in the same neighbourhood. Arch Gen Psychiatry 1998;55:393–401. 4. Taylor PJ, Leese M, Williams D, Butwell M, Daly R, Larkun E. Mental disorder and violence a special hospital study. Br J Psychiatry 1998;172:218–226. DOI: 10.1111/j.1600-0447.2005.00681.x Reply Dr Malik correctly noted that personality disorder (PD), in particular antisocial personality disorder (ASPD), is associated with a high risk of violence. This is confirmed by a number of recent studies also in case of homicide. Characteristically, these studies found individuals with ASPD to be at higher risk compared to individuals with schizophrenia. The comparison of the likelihood of homicide in e.g. schizophrenia and PD requires the psychiatric examination of an entire sample of homicide offenders regardless of any legal or diagnostic assignments. That’s what, for example, Eronen et al. in Finland did (1). However, this was not the design of our study. As the title says, it was explicitly restricted to major mental disorders (MMD). Moreover, as explained in detail in the Method section, we exclusively examined homicide offenders not guilty by reason of insanity (2, p. 101). Of course, comorbid PD and substance use disorders (SUD) play a major role also in homicide offenders with MMD (2–4). In our study, we found a statistically significantly higher likelihood of homicide in schizophrenia with compared to schizophrenia without comorbid alcoholism. Comparable cal- culations for comorbid PD in MMD would have required respective epidemiological basis data. Unfortunately, such data did not exist until now. But, the rates of comorbid PD in our sample by far exceeded the rates of PD in the general population (2, p. 103). According to Joyal et al., psychotic homicide offenders with comorbid ASPD represent a subgroup characterized by high rates of comorbid alcoholism. These offenders were less likely driven by psychotic symptoms and more likely attacked strangers compared with psychotic offenders without comorbid ASPD and SUD (5). So, PD and SUD are strong predictors of homicidal violence also in psychotic offenders. Therefore, we cannot find any contradiction between Dr Malik’s notion that PD is associated with a high risk of violence in general and our findings. His final question, however, concerning the investigation of the risk of homicide in ÔpureÕ PD can simply be answered: this was not the aim of our study and would have required a different design. Hans Schanda Justizanstalt Go ¨llersdorf Schlossgasse 17 A-2013 Go ¨llersdorf Austria References 1. Eronen M, Hakola P, Tiihonen J. Mental disorders and homicidal behavior in Finland. Arch Gen Psychiatry 1996;53:497–501. 2. Schanda H, Knecht G, Schreinzer D, Stompe Th, Ortwein- Swoboda G, Waldhoer Th. Homicide and major mental disorders: a twenty-five year study. Acta Psychiatr Scand 2004;110:98–107. 3. Shaw J, Appleby L, Amos T et al. Mental disorder and clinical care in people convicted of homicide: national clinical sur- vey. BMJ 1999;318:1240–1244. 4. Putkonen A, Kotilainen I, Joyal C, Tiihonen J. Comorbid personality disorders and substance use disorders of men- tally ill homicide offenders: a structured clinical study on dual and triple diagnoses. Schizophr Bull 2004;30:59–72. 5. Joyal CC, Putkonen P, Paavola P, Tiihonen J. Character- istics and circumstances of homicidal acts committed by offenders with schizophrenia. Psychol Med 2004;34:433– 442. DOI: 10.1111/j.1600-0447.2005.00690.x Pharmacological treatment of postpartum depression Dear editor: In the August issue of the Journal, a clinical overview article approached the important issue of perinatal mental health (1). 75 Letter to the editor
Transcript of Letter to the editor
References
1. Bechdolf A, Knost B, Kuntermann C et al. A randomizedcomparison of group cognitive-behavioural therapy andgroup psychoeducation in patients with schizophrenia. ActaPsychiatr Scand 2004;110:21–28.
2. Lewis S, Tarrier N, Haddock G et al. Randomised con-trolled trial of cognitive-behavioural therapy in early schi-zophrenia: acute-phase outcomes. Br J Psychiatry2002;181(suppl. 43):91–97.
3. Kuipers E, Garety P, Fowler D, Dunn G et al. London-EastAnglia randomised controlled trial of cognitive-behaviouraltherapy for psychosis, I: effects of the treatment phase. Br JPsychiatry 1997;171:319–327.
DOI: 10.1111/j.1600-0447.2005.00680.x
To the editor:
We read the article �Homicide and major mental disorders: a25-year study� by Schanda et al. (1) with interest. We find itlikely that schizophrenia and delusional disorder would lead toserious violence and murder with delusions being the promin-ent driving force. This would agree with the previously citedliterature (2).It was interesting to note that personality disorder was not
investigated in relation to murder. This would be expected aspersonality disorder (psychopathy) is associated with high riskof violence and recidivism. We would like to know why theauthors did not find this given it is such a strong predictor ofrisk (3, 4).
M. Malik, E. SilvaAshworth Hospital
Parkbourn, Maghull L31 1HWUK
References
1. Schanda H, Knecht G, Schreinzer D, Stompe TH, Ortwein-Swoboda G, Waldoer TH. Homicides and major mentaldisorders: a 25-year study. Acta Psychiatr Scand2004;110:98–107.
2. Doctor R. Psychodynamic lessons in risk assessment andmanagement. Adv Psychiatr Treat 2004;10:267–276.
3. Steadman H, Mulvey E, Monahan J, Robbins P, Applebaum P,Grisso T, Roth L, Silver E. Violence from people dischargedfrom acute psychiatric in patient and by others in the sameneighbourhood. Arch Gen Psychiatry 1998;55:393–401.
4. Taylor PJ, Leese M, Williams D, Butwell M, Daly R,Larkun E. Mental disorder and violence a special hospitalstudy. Br J Psychiatry 1998;172:218–226.
DOI: 10.1111/j.1600-0447.2005.00681.x
Reply
Dr Malik correctly noted that personality disorder (PD), inparticular antisocial personality disorder (ASPD), is associatedwith a high risk of violence. This is confirmed by a number ofrecent studies also in case of homicide. Characteristically, thesestudies found individuals with ASPD to be at higher riskcompared to individuals with schizophrenia. The comparison ofthe likelihood of homicide in e.g. schizophrenia and PD requiresthe psychiatric examination of an entire sample of homicide
offenders regardless of any legal or diagnostic assignments.That’s what, for example, Eronen et al. in Finland did (1).
However, this was not the design of our study. As the title says,it was explicitly restricted to major mental disorders (MMD).Moreover, as explained in detail in the Method section, weexclusively examined homicide offenders not guilty by reasonof insanity (2, p. 101).Of course, comorbid PD and substance use disorders (SUD)
play a major role also in homicide offenders with MMD (2–4).In our study, we found a statistically significantly higherlikelihood of homicide in schizophrenia with compared toschizophrenia without comorbid alcoholism. Comparable cal-culations for comorbid PD in MMD would have requiredrespective epidemiological basis data. Unfortunately, such datadid not exist until now. But, the rates of comorbid PD in oursample by far exceeded the rates of PD in the generalpopulation (2, p. 103). According to Joyal et al., psychotichomicide offenders with comorbid ASPD represent a subgroupcharacterized by high rates of comorbid alcoholism. Theseoffenders were less likely driven by psychotic symptoms andmore likely attacked strangers compared with psychoticoffenders without comorbid ASPD and SUD (5).So, PD and SUD are strong predictors of homicidal violence
also in psychotic offenders. Therefore, we cannot find anycontradiction between Dr Malik’s notion that PD is associatedwith a high risk of violence in general and our findings. His finalquestion, however, concerning the investigation of the risk ofhomicide in �pure� PD can simply be answered: this was not theaim of our study and would have required a different design.
Hans SchandaJustizanstalt Gollersdorf
Schlossgasse 17A-2013 Gollersdorf
Austria
References
1. Eronen M, Hakola P, Tiihonen J. Mental disorders andhomicidal behavior in Finland. Arch Gen Psychiatry1996;53:497–501.
2. Schanda H, Knecht G, Schreinzer D, Stompe Th, Ortwein-Swoboda G, Waldhoer Th. Homicide and major mentaldisorders: a twenty-five year study. Acta Psychiatr Scand2004;110:98–107.
3. Shaw J, Appleby L, Amos T et al. Mental disorder and clinicalcare in people convicted of homicide: national clinical sur-vey. BMJ 1999;318:1240–1244.
4. Putkonen A, Kotilainen I, Joyal C, Tiihonen J. Comorbidpersonality disorders and substance use disorders of men-tally ill homicide offenders: a structured clinical study ondual and triple diagnoses. Schizophr Bull 2004;30:59–72.
5. Joyal CC, Putkonen P, Paavola P, Tiihonen J. Character-istics and circumstances of homicidal acts committed byoffenders with schizophrenia. Psychol Med 2004;34:433–442.
DOI: 10.1111/j.1600-0447.2005.00690.x
Pharmacological treatment of postpartum depression
Dear editor:In the August issue of the Journal, a clinical overview articleapproached the important issue of perinatal mental health (1).
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Letter to the editor
