[Increasing criminality in patients with schizophrenia: fiction, logical consequence or avoidable side effect of the...

The reforms of general mental health care aimed at a substantial improvement of the situation of the mentally ill. We examined the question of a possible association between the mental health reforms and the steady increase of the population of forensic mental hospitals becoming apparent since the introduction of community psychiatry.

All recent publications report a moderate albeit statistically significantly increased risk of criminality in patients suffering from schizophrenia, which becomes more obvious in severe, violent offences. In homicide it comes up to the 10-fold of that of the general population. Comorbid substance abuse has a substantial impact on the extent of illegal behaviour, however, even under consideration of alcohol abuse the risk of homicide amounts to about the 7-fold of that of the general population. Nearly all European countries give account on a remarkable increase of the incidence and prevalence rates of mentally disordered offenders. Patients suffering from schizophrenia are disproportionately affected by this development. However, the substantially increased risk of homicide in schizophrenic patients, reported already in the pre-reform era, remained stable over time. Accordingly, the rate of patients admitted to forensic-psychiatric treatment because of offences of minor severity is on the rise.

This development cannot be explained by single details of the mental health reforms, which show remarkable regional differences concerning numbers of mental hospital beds, ways of service provision, legal preconditions and rates of criminality and substance abuse. Rather, national and international data suggest changes of general societal attitudes to be the crucial factor. They have resulted in changes concerning the self-understanding of the representatives of modern mental healthcare. As aggressive behaviour is not integrated in the understanding of schizophrenia of present-day psychiatry, the objective needs of a subgroup of severely and chronically ill psychotic patients with high rates of comorbid substance abuse, lack of insight and compliance are increasingly neglected. The denial of these facts promotes the shift of 'difficult-to-treat patients' into forensic-psychiatric facilities and damages the reputation of psychiatry.