August 15, 2012

Preventing Violence in First-Episode Psychosis

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Olav B. Nielssen, MCrim, PhD, FRANZCP, and Matthew M. Large, MD, FRANZCP

St Vincent’s Hospital, Darlinghurst, New South Wales, (Dr Nielssen) and University of New South Wales, Sydney, Australia (Dr Large)


While working in a prison hospital in the early 1990s (O.B.N.), a personal observation was made that most serious violence by the mentally ill seemed to take place before psychiatric treatment was initiated. Ten consecutive patients admitted for treatment of schizophrenia after killing somebody, usually a close family member, had never had any form of treatment and were in their first episode of psychosis. Much of our subsequent research has examined this observation, which was confirmed not only in our data but in studies from all over the world.

What does this finding mean? It means that the first episode of psychosis can be a psychiatric emergency, and urgent treatment can prevent some acts of severe violence by the mentally ill. It means that mental health laws that do not allow early involuntary treatment until there is proof of harm—for example, by killing somebody—can actively contribute to these tragedies. It means that we have to extend early intervention services to schools, colleges, and juvenile justice facilities and also to raise community awareness of emerging mental illness to try to locate and treat people with psychosis sooner.

The repeated mass shootings by people who are now known to have been in the first episode of mental illness, such as Jared Loughner in Tucson, have led to a call for more background checks for mental illness when weapons are purchased. However, background checks will usually miss the people who are the most dangerous—those who have never been treated. Can we suggest a more radical solution? The public health initiatives that have had the greatest impact on rates of, for example, suicide are not more counselors or risk assessments, but the removal of lethal means such as barbiturates, tricyclic antidepressants, cars without catalytic converters, and—dare we say it?—regulations on the types of guns that private individuals can own.

After a notorious mass shooting in Australia in 1996, the private ownership of automatic and semi-automatic weapons was severely restricted, and uniform regulations were imposed on the licensing of shooters and the registration and storage of firearms. In the 16 years since the changes to the laws, there have been no mass shootings (touch wood). The homicide rate in Australia has fallen to the lowest on record, and suicide using a firearm has become much less common. You can still have all manner of guns in Australia if you really want them. You just have to follow the rules. Does the right to bear arms mean you have a right to nuclear arms? Sensible firearms regulation would be a life-saving public health measure.

Financial disclosure:Dr Nielssen has received speakers fees from AstraZeneca in the past 2 years; Dr Large had no relevant personal financial relationships to report.​

Category: Psychosis , Schizophrenia
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15 thoughts on “Preventing Violence in First-Episode Psychosis

  1. This speaks to the larger issue of what constitutes a “danger to one’s self or others”. It is very frustrating to watch friends and loved ones descending into psychosis knowing that civil rights legislation stands in the way of proper and timely treatment. Why, for example, is psychosis not deemed to be harming the one experiencing it? If the legal system recognized this then people experiencing psychosis (first episode or otherwise) would receive better treatment. In the case of bipolar disorder mania usually leads to severe depression which carries with it a huge risk for suicide. Mood episodes contribute to cognitive impairment which is harmful in its own right. Psychosis associated with schizophrenia tends to alienate those that the person with schizophrenia needs to help cope with the illness. I await the day when there is a reliable biological marker for psychosis AND that the very experience of psychosis is recognized as posing a threat to the person experiencing it.
  2. The article touches a crucial point: ¿how to prevent a first pshycotic episode?, and still more difficult ¿how to know if the first episode will turn the individual violent againts other people?. There are no easy answers, but it is very clear that firearms must be controlled to avoid tragedies.
  3. I suppose the question of early intervention would best be addressed by a better diagnosis of schizophrenia during the prodromal period. This is often difficult to do and much resisted by patients, family and friends. The issue of firearms control is cogently presented but the resistances in our society deeply rooted in our history and traditions. Perhaps, sadly, it will only be addressed after “individuals” do start bearing “nuclear” arms.
  4. I thinks we have to add others factors like accesebility of drugs ,like fake marijuana ,K2,pcp ,cocaine ,LSD .All this drugs cause psychosis ,impulsive dangerous behavior .We had some cases of aggression and wild savage behavior in different states.
  5. Violence, aggression, and homicide can be prevented but the idea seems foreign to anyone who has not practiced inpatient psychiatry and treated a lot of aggressive patients. It takes recognition that this can occur and a combination of factors including appropriate commitment laws need to be in place. I have a number of comments posted on my blog including this one:

    I also think that we need to introduce the idea that aggressive or homicidal thoughts need as open a discussion as suicidal thinking does for suicide prevention. I don’t think we need prodromal diagnoses or biological markers. The disorder should be obvious to the treating psychiatrist, the problem as the original post points out, is getting the person into treatment before any catastrophic event happens and making sure that treatment is adequate.

    From a purely political standpoint, these measures can be taken without addressing the firearms issue. I think a good starting point there is to address how the scientific study of the problem has been stifled in Congress:

  6. In low income area where one of my clinics is located, the issue of firearms possession has nothing to do with registration or legal acquisition. The gangs already have illegal fully automatic (basically machine guns) weapons that the ordinary civilian has no access to.
    In Israel and Switzerland civilians have weapons which are not involved in suicide/homicide.
    There is an attitude towards violence, perhaps best represented by what we see on television that seems to have more to do with the public attitude than mere possession of a weapon does. This was noted some years ago by a psychiatric colleague whose name escapes me.
    It is that cultural attitude that needs to be addressed, although how this might be done is a mystery to me.
  7. To obtain a concealed carry permit, most states require satisfactory completion of a firearms safety course. It includes classes and videos on situational awareness and basic defensive shooting, followed by live fire exercises at a range. Safe handling of firearms, and avoiding rather than escalating crises are emphasized.
    If, in that Colorado theater, only one person besides the psychotic mass murderer had possessed a firearm, there probably would have been a lot fewer innocent victims, and one more dead murderer.
  8. Tom has a very good point. As a HH nurse for many years in the “duece” area of Phoenix I have seen both sides of the picture. all the Gangs have guns and so do the private citizens. When Phoenix passed the castle doctrine and made concealed carry easily accessable to qualilfied people the gun crime rate dropped 60% in the first 3 months. Philip, there would not have been a disorganized shootout. go to a concealed weapons class than you can tell me what you learned.
  9. “…civil rights legislation stands in the way of proper and timely treatment”. Do you really believe that people who are mentally ill shouldn’t have civil rights? What about criminals who are not mentally ill?
  10. The issue of preventing violence and aggression can be addressed independent of the firearms issue. The anecdotes and data of firearm possession generally fall out on which side of the issue that you come down on. The reality of mass shooting incidents is that there is hardly ever a person on the scene who is licensed to carry a firearm (apart from the law enforcement people who arrive) who stops the shooter. Waiting for larger numbers of citizens to carry weapons to increase the probability that this will happen one day seems like a futile strategy to me – especially when practically all other options are essentially unexplored.
  11. Mental health laws allowing compulsory admission and treatment are needed to prevent persons suffering from psychosis who may pose a danger to others and themselves, from inflicting harm. Paranoid delusions, command hallucinations and other phenomena may certainly indicate a high probability of causing harm. Certainly human rights considerations should also to ensure that the person receives appropriate treatment, despite their lack of insight and unwillingness to receive treatment voluntarily.
  12. A woman in my neighborhood, I have known for 20 years has a father who is a career criminal and mother who is chronically psychotic. This woman is now in her late 40s and has developed an extensive delusional system that involves paranoid thoughts about several specific neighbors. Sadly her condition has deteriorated and she is no longer able to function at work. She has been arrested numerous times now for various acts against these neighbors. They all live in fear of her and one of them reported her for approaching him in a car with a gun. In court it became “his word against hers” and there was not enough evidence to convict her. The woman remains psychotic and preoccupied that “these people won’t stop until they destroy me”. There do not appear to be laws to protect our neighbor from her.
  13. The detective and prosecutors in the case have both spoken with me because they do not know what to do. There are apparently no laws in this state preventing the woman from having a gun in her house. I have said that the combination of continued psychosis, her history of actions based on delusional thoughts and stalking behavior are all very worrisome.

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