The Use of Scientific Evidence about Schizophrenia and Violence in Clinical Services

Abstract

This special section of the Canadian Journal of Psychiatry focuses on violent behaviour by persons with schizophrenia. Three brief but informative articles critically review clinically relevant, up-to-date evidence. Hodgins and Klein draw attention to new evidence about the aetiology of violence among people with schizophrenia, potent predictors of violence, and the need to restructure psychiatric services such that individuals developing schizophrenia are assessed for past and current violent behaviour and to provide them with a host of treatments targeting both their violent behaviours and the schizophrenia. Quinn and Kolla review the evidence on effective treatments, concluding that randomized clinical trials (RCTs) are urgently needed to bolster the evidence base. Swartz, Bhattacharya, Robertson, and Swanson review the evidence about outpatient commitment, most of which comes from the United States. However, as noted by Hodgins and Klein, some people with schizophrenia have a long history of antisocial behaviour, ways of thinking, and attitudes that lead to noncompliance with psychiatric care. The review by Swartz et al. shows that outpatient commitment does improve compliance. However, most of this evidence is not being used by psychiatric services. First-episode clinics do not generally assess for past and current antisocial and aggressive behaviour, nor do they have the resources to treat these behaviours, including substance misuse, along with the schizophrenia. A subgroup of their patients will be prosecuted for a violent crime. If it is proven and they are judged not responsible due to a mental disorder, in most countries, they are sent to a forensic hospital. Patients are initially discharged on a court order under the jurisdiction of a provincial review board and, in other countries on similar court orders, with powers to quickly return the patients to the forensic hospital if the conditions of their discharge are not respected or their mental status deteriorates. Thus, orders for outpatient treatment begin within forensic services. I have been the director of a large forensic psychiatric service with a geographic catchment area of 6,000,000 inhabitants for 30 years. Most patients are men with schizophrenia. They remain in hospital, on average, 5 years, with gradual access to the community long before final discharge. Throughout these years, I have done my utmost to try and base our clinical services on scientific evidence. Powerful challenges, however, have and continue to block progress towards this goal. First, who among the clinical staff has the responsibility and the time to keep up with the literature and identify new effective treatments and assessment tools? Second, once a treatment program has been shown to be effective or an assessment tool has been shown to be valid, how are funders of a clinical service to be convinced to pay for staff training and implementation of the new program or instrument? How are competent trainers identified? Third, which staff should be trained to achieve the best results, and who covers their usual clinical responsibilities while they are being trained? Probably the biggest challenge is implementing the new treatment within the ongoing treatment program of the institution as it involves combatting resistance to change among staff. After much reading and long discussions with C. D. Webster, in 1995 I implemented the use of the Historical Clinical Risk–20 (HCR-20) for assessing risk of violent behaviour in both inpatient and outpatient services, soon followed by Version 2 in 1998. This initiated a culture change within our service. However, even having obtained the necessary funds for staff training and implementation of the HCR-20,