Background Despite the increased interest in female offending trajectories over the last decades, knowledge is still limited. Aim To meet the need for more knowledge on female offending trajectories by studying sex differences in criminal career patterns. Method Data on 518 female and 2567 male offenders up to age 30 from the Swedish longitudinal Project Metropolitan study were analysed using latent class analysis. Results The female offenders were much less predisposed to offend than the males, but when they did, they tended to follow a similar set of trajectories to males in their criminal development over time. Four criminal career patterns were identified for each sex. Two patterns were the same between the sexes, and two were gender unique. All career patterns had meaningful and distinct associations with crime characteristics. Conclusions Our study presents indicators relating both to gender differences and to heterogeneity within the group of female offenders. One important finding was the identification of an adult-onset offender group unique to females. This group was characterised by high criminal activity over the years following their late onset. Further research will focus on the childhood origins, pathways and outcomes of different female antisocial and criminal careers.

This chapter explores the female patterning of crime and factors that differentiate between these patterns. The theoretical frame considers the developmental course of criminality and some common developmental pathways or trajectories. This perspective is concerned with identifying factors across people’s lives that account for both stability and change in antisocial behavior and crime. The family, school, and peer groups, expressed in social bonds and social networks, are the dominant sources of social control during childhood and adolescence and although childhood oppositional behavior tends to attenuate these important sources of social control, this is not invariably the case. The chapter has a special focus on a female pattern of crime that has not previously been given so much attention in research, namely an adulthood-onset trajectory. The overall aim is to contribute to a better understanding of factors that contribute to the development of different criminal careers among females by studying individual and social characteristics and how such factors interact to change and shape criminal involvement over two critical developmental phases: early adolescence and the transition into young adulthood for a cohort of Swedish girls.

Background: Patients diagnosed with schizophrenia display poor premorbid adjustment (PPA) in half of the cases. Attention deficit/hyperactivity disorder (ADHD) and conduct disorder (CD) are common child psychiatric disorders. These two facts have not previously been linked in the literature. Aims: To determine the prevalence of ADHD/CD problems retrospectively among patients with psychoses, and whether and to what extent the high frequency of substance abuse problems among such patients may be linked to ADHD/CD problems. Method: ADHD and CD problems/diagnoses were retrospectively recorded in one forensic (n = 149) and two non-forensic samples (n = 98 and n = 231) of patients with a psychotic illness: schizophrenia, bipolar or other, excluding drug-induced psychoses. Results: ADHD and CD were much more common among the patients than in the general population—the odds ratio was estimated to be greater than 5. There was no significant difference in this respect between forensic and non-forensic patients. Substance abuse was common, but substantially more common among patients with premorbid ADHD/CD problems. Conclusions: Previous views regarding PPA among patients with a psychotic illness may reflect an association between childhood ADHD/CD and later psychosis. The nature of this association remains uncertain: two disorders sharing some generative mechanisms or one disorder with two main clinical manifestations. Childhood ADHD and particularly CD problems contribute to the high frequency of substance abuse in such groups.

The abuse of flunitrazepam (FZ) compounds is worldwide, and several studies have reflected on the consequences with regard to violence, aggression and criminal lifestyle of FZ users. Criminals take high doses of FZ or some other benzodiazepines to "calm down" before the planned crime. There is support from earlier studies that most likely, all benzodiazepines may increase aggression in vulnerable males. Chronic intake of high doses of FZ increases aggression in male rats. Because psychopathy involves aggression, we have examined whether psychopathy as well as any of the four facets of the Psychopathy Checklist-Revised (PCL-R) (Interpersonal, Affective, Lifestyle and Antisocial) are related to different substance use disorders, with the focus on FZ. We have also examined the relationship between each PCL-R item and FZ use. Participants were 114 male offenders aged 14-35 years, all of whom were convicted for severe, predominantly violent, offences. Substance use, including FZ, was not more common in those who scored high in psychopathy. Use of FZ was more common in offenders who scored high in Facet 4 (Antisocial) of the PCL-R (odds ratio = 4.30, 95% CI 1.86-9.94). Only one of the PCL-R items, "Criminal versatility", was significantly associated with FZ use (odds ratio = 3.7). It may be concluded that intake of FZ has a specific relationship to only one of the facets and not to psychopathy per se. ; The findings have also important theoretical implications because Facet 4 is not a key factor of the construct of psychopathy. Clinical implications of the article: We have used the new two-factor and four-facet theoretical model of psychopathy in the young offender population, many of them with one or more substance use disorders. The present results suggest that antisocial behavior defined by Facet 4 (poor behavioral control, early behavior problems, juvenile delinquency, revocation of conditional release and criminal versatility) in the studied subjects is more typical for FZ users than it is for non-FZ users. This may have implications for assessment and treatment. Clinicians should be aware that criminals with high scores on Facet 4 have a more than fourfold odds of being a FZ user. This conclusion has an important clinical implication because FZ abuse is very common and is not always the focus of a forensic psychiatric assessment. ;

Strong self-esteem is related to good psychological health. Dyslexia has a negative effect on self-esteem, but this effect depends on support levels at home and/or school. Women with dyslexia are an under investigated group, and it has been suggested that female dyslexics should be given special attention from teachers with a view to improving their self-esteem. This paper set out to compare levels of self-esteem in women with dyslexia and normative women, and to investigate relationships between dyslexic problems and self-esteem. It was hypothesized that women with dyslexia would have a weaker self-esteem. We have assessed dyslexia, using a Swedish battery of standardised pedagogical, IQ, and neuropsychological tests, and the self-esteem of twelve young women (mean age 19 years; range 16-30), using a Swedish questionnaire that distinguishes between different dimensions of self-esteem (physical characteristics, talents and gifts, psychological health, relationships with parents and family, and relationships with others). Comparative (t-tests) and correlational (Pearson’s correlations and stepwise multiple regression analyses) statistical methods were performed. The study subjects had a weaker self-esteem than that of a normative sample of females (N = 313) in all dimensions, except for the dimension of relationships with parents and family. Spelling ability was related to “Physical characteristics” (negative) and to “Relations with parents and family” (positive). Moreover, speed of reading was related to “Psychological health” (positive). The use of questionnaires that distinguish between different dimensions of self-esteem and a larger sample is recommended in future studies.

Previous neuropsychiatric studies suggest a relationship between reading disability and cognitive impulsivity. This relationship is not entirely explained by the high comorbidity between reading disability and attention deficit hyperactivity disorder (ADHD), as children with a co-occurrence of these disorders tend to be more impulsive than those with ADHD only. Other research has demonstrated that poor verbal skill (irrespective of the presence of dyslexia) deficits in executive functions and impulsivity are important risk factors for criminal behaviour. The present study bridges these two research traditions by examining whether patients undergoing forensic psychiatric investigation who also have dyslexia, have a cognitive style characterized by impulsivity. Male forensic patients (mean age 27 years, range 16–35) with (n = 9) and without (n = 13) dyslexia were evaluated on the computerized EuroCog test battery. The findings suggest that patients with dyslexia tend to use a cognitive impulsive style and suggest a more direct link between dyslexia and cognitive impulsivity that is not mediated by the presence of ADHD. In order to identify treatment needs and tailor treatment accordingly, forensic patients should be assessed with respect to poor verbal skill, dyslexia and impulsivity.

OBJECTIVE: To investigate the recently defined Positive and Negative Syndrome Scale for Schizophrenia remission criteria in a naturalistic setting of psychotic patients; to identify causal factors that change remission status; and to validate the criteria against global indices of illness, cognitive functions, and social outcome. METHODS: This was a longitudinal naturalistic study of 162 patients, diagnosed with schizophrenia or schizophrenia-related psychotic disorders (mean illness duration, 11 years) and treated with risperidone at study entry. Symptoms, drug treatment, cognitive function, and social outcome were measured at baseline and annually for 5 years. Remission was constructed retrospectively with only indirect data on stability over time. RESULTS: At study entry, 40% of the patients with schizophrenia were in symptomatic remission, stabilizing between 55% and 60% after a few years. The need for hospitalization became less frequent over time; initially 31%, dropping to 7% by years 4 and 5. Many patients went in and out of remission. Remission was strongly associated with global indices of illness, with intact insight and with social outcome (except work/studies) but not with cognition or medication. CONCLUSIONS: In spite of certain weaknesses of the study, we may conclude that current definition of remission is primarily a symptomatic measure, covering a subset of symptoms, some of which are not schizophrenia-specific. Although the definition may be clinically relevant, we must be aware of the risk that the connotation of the word could induce too much focus on symptom control.

Swedish penal law does not exculpate on the grounds of diminished accountability; persons judged to suffer from severe mental disorder are sentenced to forensic psychiatric care instead of prison. Re-introduction of accountability as a condition for legal responsibility has been advocated, not least by forensic psychiatric professionals. To investigate how professionals in forensic psychiatry would assess degree of accountability based on psychiatric diagnoses and case vignettes, 30 psychiatrists, 30 psychologists, 45 nurses, and 45 ward attendants from five forensic psychiatric clinics were interviewed. They were asked (i) to judge to which degree (on a dimensional scale from 1 to 5) each of 12 psychiatric diagnoses might affect accountability, (ii) to assess accountability from five case vignettes, and (iii) to list further factors they regarded as relevant for their assessment of accountability. All informants accepted to provide a dimensional assessment of accountability on this basis and consistently found most types of mental disorders to reduce accountability, especially psychotic disorders and dementia. Other factors thought to be relevant were substance abuse, social network, personality traits, social stress, and level of education.

Background In the Swedish society, as in many other societies, many children and adolescents with mental health problems do not receive the help they need. As the Swedish society becomes increasingly multicultural, and as ethnic and economic residential segregation become more pronounced, this study utilises ethnicity and neighbourhood context to examine referral pathways to child and adolescent psychiatric (CAP) clinics. Methods The analysis examines four different sources of referrals: family referrals, social/legal agency referrals, school referrals and health/mental health referrals. The referrals of 2054 children aged 11-19 from the Stockholm Child-Psychiatric Database were studied using multilevel logistic regression analyses. Results Results indicate that ethnicity played an important role in how children and adolescents were referred to CAP-clinics. Family referrals were more common among children and adolescents with a Swedish background than among those with an immigrant background. Referrals by social/legal agencies were more common among children and adolescents with African and Asian backgrounds. Children with Asian or South American backgrounds were more likely to have been referred by schools or by the health/mental health care sector. A significant neighbourhood effect was found in relation to family referrals. Children and adolescents from neighbourhoods with low levels of socioeconomic deprivation were more likely to be referred to psychiatric child and youth clinics by their families in comparison to children from other neighbourhoods. Such differences were not found in relation in relation to the other sources of referral. Conclusions This article reports findings that can be an important first step toward increasing knowledge on reasons behind differential referral rates and uptake of psychiatric care in an ethnically diverse Swedish sample. These findings have implications for the design and evaluation of community mental health outreach programs and should be considered when developing measures and strategies intended to reach and help children with mental health problems. This might involve providing information about the availability and accessibility of health care for children and adolescents with mental health problems to families in certain neighbourhoods and with different ethnic backgrounds.

Background: Externalizing symptoms in children (aggression, oppositionality, prop- erty and status violations), and the Attention Deficit Hyperactivity Disorder (ADHD) triad of problems (inattention, hyperactivity, impulsivity) display a substantial co- morbidity. The “short temper” problem is common to these syndromes, which are predictive of a range of negative life outcomes including substance abuse and crimi- nality in adulthood. There is a gender gap for the syndromes (boys are more af- fected), for criminality (men are more criminal) and knowledge (we know less about girls’ criminal careers). Aims: The main aim was to compare crime rates and crime profiles among former Child and Adolescent Psychiatric (CAP) patients with cor- responding data for matched controls, focusing externalizing and internalizing psy- chiatric symptoms, sex and adverse social factors. Method: Data for 6055 former CAP-Stockholm outpatients were extracted from available treatment registers. For each CAP patient, two matched controls from the general population were randomly selected from the same area of residence, of the same sex and with the same year of birth (N approx. 12,000). Data on criminality for these individuals were obtained from a Swedish police register which also includes crimes committed prior to age 15. Results: Overall, twice as many former CAP patients were registered for crimes at a mean age of 21.4 compared to the controls. The over-representation was larger for crimes of violence. Females were registered for a much lower number of crimes, par- ticularly crimes of violence (gender gap). The gender gap among the CAP patients was smaller than among controls. Compared with controls, CAP patients character- ized by externalizing problems at referral had an odds ratio (OR) for crimes of 5 for males and 10 for females. Neglect was the only adverse social factor which was asso- ciated with a higher crime rate and affected boys more than girls. Compared to pre- vious Swedish CAP cohorts, the criminality of the current cohort was much higher. Conclusion: In-depth studies of female crime careers characterized by externalising problems are needed. Child psychiatric services must find new and more effective ways of identifying and treating children with such problems, regardless of sex. The findings can guide the choice of strategies which will reduce crime rate.

Only a minority of patients treated with antipsychotics in clinical studies continue their treatments throughout a longer study period. Few studies address this issue from a lifetime perspective. In this naturalistic study, we aimed at analysing the prescription pattern of antipsychotic drugs among a sample of Swedish patients with a diagnosis of psychotic illness, from the first contact with psychiatry (typically between 1973 and 1997) until the last written note in the case history documents. A retrospective descriptive analysis was performed of all case history data of 66 patients diagnosed with schizophrenia or related psychotic disorders. Patients with schizophrenia were prescribed antipsychotic medication more than 90% of the time. Each patient generally had been prescribed several (up to 16) different antipsychotic drugs and a quarter of the patients had been prescribed two or more antipsychotics for a third of their prescription time. Patients with psychosis were exposed to a cumulatively growing number of antipsychotics. Various factors, including clinician and patient expectations, and specific strengths and limitations of available antipsychotics may account for frequent medication changes over time.

The relation between criminality and mental illness is very sensitive, stated Sten Levander. Usually people do not want to add to the stigma of mental illness. Also, social and psychological explanations of mental illness are preferred over biological or – even worse – genetic explanations.

Psykiska störningar är vanliga, och vissa av dem är kopplade med en betydligt ökad brottslighet. Ju mer man vet om dessa störningar desto bättre kan man hantera de problem som uppstår i närkontakten med sådana, oavsett om man är polis, arbetar inom socialtjänst, kriminal-vård eller psykiatri, eller är väktare. I dessa professioner möter man inte bara brottslingar – man möter också deras offer och ska anlägga ett psykologiskt första-förband. Man ställs också inför situationer där man får ansvar för initiala medicinska bedömningar. Läser man texten bör man bli bättre rustad i sådant arbete.

Socialstyrelsens rättsliga råd får, på grund av en praxisgrundande dom i Högsta domstolen, alltid rätt i domstolsprövningar. Detta är inte en kvalitetsindikator, det talar för att något är fel i systemet, anser Sten Levander.

Objective: Explore how clinicians select drug treatment based on symptoms, side effects and patient factors, including patient participation in the process, and the association between these factors and attitudes towards drugs.

Method: A cohort of 166 patients initially treated with risperidone was followed with yearly assessments over 5 years. At the end of the study, 101 patients were evaluated of whom 58 were still treated with risperidone.

Results: More women than men remained in the study, and on the initial medication. The most common reason for medication switch was lack of efficacy. Clinicians and patients agreed well in their global ratings of medication effects and side effects. Robust associations between switch decisions and patient characteristics including symptoms and side effects could not be identified. The effects of switches were rated as better by the clinicians than by the patients. Negative drug attitudes were associated with pronounced positive symptoms (threshold effect), whereas the corresponding association with 'lack of judgment and insight' was linear over the whole range.

Conclusion: The decision-making process appears to have many unknown components, and may benefit from more active patient involvement by using structured clinician and patient rating scales for monitoring the treatment. Such shared decision-making may improve compliance.

Objective: To examine nicotine use and its correlates among psychotic patients.

Method: Longitudinal naturalistic study of 176 patients, diagnosed with schizophrenia or schizophrenia-related psychotic disorders, and treated with risperidone at study entry. Levels of nicotine use (smoking, snuffing) were measured along with other relevant ratings and measurements (symptoms, drug treatment, side effects, weight, cognitive functions and outcome) at baseline and once yearly for 5 years.

Results: Nicotine use was twice as common as in the general population. Only few nicotine users had started after onset of psychoses. We could not find any differences among nicotine users and non-users in diagnosis, symptoms, side effects, weight, cognitive functions, personality and outcome, cross-sectionally and longitudinally, ruling against the 'self-medication' hypothesis.

Conclusion: A parsimonious interpretation of the findings is that patients suffering from psychosis fail to desist from nicotine rather than experience significant positive effects of the usage.

BACKGROUND: Poor self-control is a strong correlate of criminal propensity. It is conceptualized and operationalized differently in criminology than in other scientific traditions.

AIMS: (1) To verify the dimensionality of the criminological Grasmick self-control items, other self-regulation items and morality ones. (2) To re-interpret the dimensions using a clinical perspective, a taxonomic/diagnostic model and references to possible "biological underpinnings." (3) Validate the dimensions by associations with crime.

METHOD: Population: all persons born 1995 in Malmö and living there at age 12. A random sample (N = 525) filled in a comprehensive self-report questionnaire on themes like personality, crime/abuse and social aspects at age 15, 16 and 18. Age 18 data were analysed: 191 men and 220 women.

RESULTS: Self-regulation items were 4-dimensional: ADHD problems (Behavior control and Executive skills) and two Aggression factors. Morality items formed a fifth dimension. Negative Affect and Social interaction factors covered the rest of the variance. The validity of these factors was backed up by correlations with similar items/factors. Self-regulation subscales predicted crimes better than the Grasmick scale; an interaction with morality improved prediction still further. Sex differences were over-all small with three exceptions: Aggression, Morality and Negative affect.

CONCLUSION: We identified four dimensions of the 20-item Grasmick instrument: Cognitive action control (impulsiveness/sensation seeking, response inhibition), Executive skills/future orientation, Affective/aggression reactivity and Aggression control. All should be possible to link to brain functional modules. Much can be gained if we are able to formulate an integrated model of self-regulation including distinct brain functional modules, process-and trait-oriented models, relevant diagnoses and clinical experiences of individual cases.

Objective: Explore the long-term course of schizophrenia and related disorders.

Method: Naturalistic study of 225 patients initially treated with risperidone (monotherapy or in combination with other psychotropic drugs) over 5 years.

Results: Stable symptomatology and side effects were observed. Clinician GAF scores were 55-61, but patients' self-ratings were higher. Clinician and patient CGI scores were at the same level. Annual in-patient days decreased but days in sheltered accommodations increased still more. Only 12% of the patients studied or worked full-time. One in four had no social contacts except with staff. Eight patients died during the 5 years.

Conclusion: The findings underline the chronicity and seriousness of psychotic disorders in terms of social outcome and, indirectly, the low quality of life of this group of persons. Patients were generally well aware of their illness and able to sort out symptoms from drug side effects. This opens for more active involvement of patients in monitoring their own treatment.

OBJECTIVE: To explore the direct and indirect costs in a cohort of 225 risperidone-treated patients with schizophrenia followed up annually during 5 years. METHOD: Data on costs for medication, hospitalization, sheltered living and productivity losses, as well as degree of social isolation, were collected. RESULTS: The direct costs were dominated by hospitalization and sheltered living expenses, while drug costs only represented 7% of the direct costs. Indirect costs represented 43% of the total costs during the 5 years. About 12% worked full-time, and 12% worked part-time, implying large productivity losses. As a consequence of the national mental health care reform, a substantial shift of costs from hospital care to sheltered living took place on the national level, but the reduction of hospital days for the study patients over time was much larger suggesting that the switch from first to second generation compounds was therapeutically successful. A high degree of social isolation was seen, with more than 20% being completely without social contacts and 30% seeing friends/relatives less often than once a week. CONCLUSION: The economic costs of schizophrenia are high and driven by the need for assisted living and hospitalizations, together with productivity losses. In addition, the intangible costs, such as social contacts, are also high.

Objective: To investigate a series of consecutive suicides at a psychosis clinic by using a psychological autopsy technique. Method: The clinic serves an adult population of 225,000 individuals, of whom 0.5% have regular contact with the clinic. During a 7½-year period, 23 men and nine women committed suicide, which corresponds to an odds ratio of 14. Results: Most patients were schizophrenic, and 24 were outpatients. Suicide methods were violent in all but two cases. Nineteen had a history of at least one suicide attempt, and 24 were known to have had suicidal ideation. More than half had no social contacts over the last year except with psychiatric staff. The median time between the last contact with the psychiatric services and the suicide was 4 days. No warning signs were noted. At the time of death, 3 of the 24 who were prescribed antipsychotics, and none of the 10 who were prescribed antidepressants had plasma levels of the corresponding drug. Conclusion: Findings of special interest are the lack of forewarnings and the poor drug compliance. Patients appear to have played "business as usual" with the care-givers, and did it well. Is it a sign of health and despair, or illness?

The objective of the study was to validate a self-administrated symptom rating scale for use in patients with schizophrenia spectrum disorders by item analysis, exploration of factor structure, and analyses of reliability and validity. Data on 151 patients, initially treated by risperidone, obtained within the framework of a naturalistic Phase IV longitudinal study, were analysed by comparing patient and clinician ratings of symptoms, side-effects and global indices of illness. The Symptom Self-rating Scale for Schizophrenia (4S) is psychometrically adequate (item analysis, internal consistency, factor structure). Side-effect ratings were reliable. Symptom ratings displayed consistent associations with clinicians' ratings of corresponding symptom dimensions, suggesting construct validity. Patients had most difficulties assessing negative symptom items. Patients were well able to assess their own symptoms and drug side-effects. The factor structure of symptom ratings differs between patients and clinicians as well as how they construe global indices of illness. Clinicians focus on psychotic, patients on affective symptoms. Use of symptom self-ratings is one way to improve communication and thereby strengthen the therapeutic alliance and increase treatment adherence.

Abstract Objectives. There is a need for an observation scale for assessment and monitoring of acutely psychotic patients. Milestones based on such ratings should be defined, similar to the PANSS-based Remission criteria. FAST-O is such an instrument (11 items and a CGI rating). Methods. Reliability, validity and factor structure were analyzed in four separate studies-most importantly in one study of 33 chronic forensic in-patients rated concurrently by three independent raters, and another study of 91 Psychiatric Intensive Care Units patients and 20 newly admitted forensic patients, rated twice, each time by two independent raters. Results. The factor structure was simple, two factors and an orphan item (Depression). Reliability was adequate on item (>0.75) as well as scale (>0.85) level. There was no bias related to the rater's professional background. The instrument was sensitive to change. Percentile-based algorithms allow characterization of patients and groups. Tentative treatment milestones are defined; a clinical state "half-way" between the acute state and remission. Conclusions. FAST-O is a reliable, valid and easy to implement observation scale for patients with a psychotic illness, which can be used without bias by all staff.

Background: Symptom control by drug treatment is the most important task in routine clinical care of patients with schizophrenia. Structured assessment methods are needed in this task but not used much. The US-developed Positive and Negative Syndrome Scale (PANSS) is a standard tool for symptom assessment. The Psychosis Evaluation tool for Common use by Caregivers (PECC) was constructed in Europe some years ago, with the intent to overcome some of the PANSS drawbacks. Aims and methods: To validate PECC on three longitudinal cohorts of schizophrenic patients representative of Swedish outpatients (n = 225, six assessments over 5 years), international forensic patients (n = 186) and matched non-forensic controls (n = 116), five assessments over 2 years for both. Results: The factor structure of PECC appears to be highly robust. Norm values (in percentiles) were calculated on the materials. Such data provides for analyses of symptom profiles and improvement over time measured in absolute numbers. Forensic patients appear to have a much lower symptom load (except for cognitive symptoms) than the other groups. Forensic controls had much shorter inpatient times than any other group and never caught up with respect to symptom control, even after 2 years. These differences suggest that the scale is clinically valid. Conclusion: PECC has a more robust factor structure than PANSS and is simpler to use. Percentile norms have been constructed for outpatients with schizophrenia in general and forensic psychiatry. Percentile scores are accessed readily by the net. PECC is available in many languages. Its separate self-harm item may improve assessments of suicide risk among patients with schizophrenia

Objective: This study was designed to explore the concentration of schizophrenic patients to socially disadvantaged areas in Malmö. Method: A case-finding study of schizophrenia was combined with a victimisation survey. Data was factor-analysed and visualised using geographical information system software. Results: The schizophrenic patients lived predominantly in socially disorganised areas characterised by high levels of disorder, fear of crime and victimisation. Regression analyses showed that local informal social control and concrete fear of crime explained one-third of the variance in schizophrenia prevalence. Measures of victimisation and social disorder, together with schizophrenia prevalence, were found to explain 52% of the variance of concrete fear of crime in the neighbourhood. Conclusions: Our hypothesis is that these circumstances cause vicious circles that tend to maintain or worsen an already negative situation, with detrimental effects on psychosocial functioning and on the quality of life of the persons with schizophrenia. Key words: schizophrenia, crime, fear of crime, victimisation, social disorganisation

De olika verktyg för riskbedömning av upprepat våld på individnivå som används inom svensk polis idag och hur de fungerar i rutinverksamhet har hittills utvärderats i begränsad utsträckning. I föreliggande rapport sammanfattas resultat från fyra studier i vilka verktygen Check-10(+), SARA:SV och Skånemodellen har utvärderats (Mellgren m.fl ., 2012; 2014a; 2014b; Svalin m.fl ., 2014). Samtliga verktyg bygger på kunskap om riskfaktorer för de olika brottstyper för vilka återfallsrisken ska bedömas och stöd- och skyddsåtgärder sättas in. Den mesta kunskapen kommer dock från andra verksamheter än polisverksamhet. Följande frågor diskuteras i rapporten: *Vilka är de ärenden som blir föremål för strukturerad bedömning och hur fungerar den initiala bedömningen som sorteringsgrund? * Bidrar processen med riskanalys till minskad upprepad utsatthet? * Kan riskanalys anses fungera väl i polisverksamhet? Den initiala bedömningen är det första steget i riskanalysens process. Om den inte fungerar är sannolikheten större att inte heller den strukturerade bedömningen i steg två fungerar. Genomgången av de ärenden som blir föremål för riskanalys med Skånemodellen, Check-10(+) och SARA:SV visar att få av alla de ärenden som anmäls under ett år bedöms strukturerat. Av dem är det endast ett fåtal där det bedöms föreligga särskilt förhöjd risk, de fl esta bedöms som låg eller medelhög risk. För att vidare svara på frågan om de mest allvarliga ärendena blir bedömda bör en uppföljning göras för ett urval av de ärenden som inte går vidare till strukturerad bedömning för att kunna jämföra återfallsfrekvensen med och utan bedömning och tillhörande stöd- och skyddsåtgärder. För samtliga undersökta verktyg och de bedömningar som genomförts utifrån dessa är det interna bortfallet stort för vissa faktorer, särskilt för de som rör gärningspersonens psykiska hälsa. * Detta innebär i praktiken att bedömningar av risk görs utan ett komplett underlag. Det i sin tur innebär att den träffsäkerhet man haft i de vetenskapliga studierna av verktygen inom andra verksamheter inte går att uppnå i polisens vardagsarbete. Förlusten i träffsäkerhet kan vara så stor att bedömningen närmar sig slumpnivån. Då är det meningslöst att alls göra riskbedömningar. * Verktygen visar låg prediktiv validitet, andelen upprepat utsatta bland ärenden som bedömts med Skånemodellen och SARA:SV är stor, till- gången till åtgärder är begränsad och åtgärdernas preventiva förmåga förefaller vara svag och kan i vissa fall antagligen öka brottsrisken. Riskbedömningarna kan vara mycket bra men om de åtgärder som vidtas på basen av riskbedömningar och ekonomiska kalkyler inte har någon effekt, t.ex. en viss brottspreventiv åtgärd som enligt kriminologisk forskning inte fungerar brottspreventivt på en viss grupp av kriminella – då är vinsterna med verksamheten små. När de första moderna riskbedömningsmetoderna lanserades i mitten av 1990-talet fokuserade man ute slutande på riskbedömningen – inte vad som skulle göras utifrån den. I dag är riskbedömningar av detta slag alltid sammankopplade med riskhanteringsåtgärder. Om ambitionen är att basera denna typ av verksamhet på vetenskap räcker det inte att utvärdera om riskbedömningarna är tillräckligt bra – vi måste också utvärdera effekten av de åtgärder som styrs av riskbedömningen. Mot bakgrund av detta är en av de viktigaste slutsatserna – och rekommendationerna – att kunskapen om hur verktygen fungerar måste öka innan rekommendationer görs. Sammanfattningsvis, leder riskanalys till minskad upprepad utsatthet för brott och kan verktygen anses fungera väl i svensk polisverksamhet? Ett kortfattat svar på frågan är: Nej, inte baserat på de utvärderingar som genomförts inom detta projekt. Kunskapen om vilka ärenden som inte bedöms är begränsad och vi vet inte om ”rätt” ärenden går vidare. Baserat på att fl est ärenden bedöms som låg eller medelhög risk är en rimlig slutsats att många högriskärenden missas. Bortfallet är ibland så högt att bedömningens validitet måste ifrågasättas, dvs. man mäter inte det man avser att mäta och en bedömning baserad på bristfällig information riskerar att bli felaktig. Detta bekräftas av att träffsäkerheten är låg och andelen upprepat utsatta hög. I tillägg är interbedömarreliabiliteten i vissa avseenden låg, både för Skånemodellen och för SARA:SV. En kritisk faktor är det första steget i riskbedömningen (screening), dvs. procedurerna för att välja ut ett begränsat antal av alla inkommande ärenden, som sedan går vidare till en strukturerad riskbedömning. Det bör vara möjligt att skapa välfungerande screening-rutiner på basen av redan kända sakförhållanden och befi ntliga databaser, dvs. aktuariska riskfaktorer som är omedelbart tillgängliga för polisen vid screeningen. Sådana riskfaktorer är ålder, kön, tidigare kriminalitet i allmänhet och våldskriminalitet i synnerhet, offer (närstående och/eller andra), brottsbredd (många olika typer av tidigare brott), vårddomar och indikatorer på missbruk. Polismyndigheten bör genomföra större utbildnings- och implementeringsinsatser samt följa upp, utvärdera och anpassa arbetet med riskbedömning av våld på individnivå. Därefter bör nationella verktyg rekommenderas och riktlinjer för arbetet tas fram. Detta kräver resurser, men menar man allvar med satsningen på riskbedömningar är detta nödvändigt. Punktinsatsernas tid bör vara förbi och det långsiktiga förbättringsarbetet inledas omgående.

I följande rapport sammanfattas resultatet från en utvärdering av Check-10(+). Check-10(+) är en av de strukturerade checklistor för bedömning av risk för upprepat våld på individnivå som används inom svensk polis. Rikspolisstyrelsen föreslog efter en inspektion av polismyndigheternas rutiner vid riskanalys (Rikspolisstyrelsen, 2010) att de metoder och verktyg som används inom svensk polis för att bedöma risken för upprepat våld på individnivå bör utvärderas. Detta baserades på att de olika metoder för riskanalys och specifika verktyg för riskbedömning som tillämpas inom svensk polis har utvärderats i begränsad utsträckning, och att kunskapen om hur verktygen fungerar är bristfällig. I en uppföljande inspektion av myndigheternas arbete med riskanalys (Rikspolisstyrelsen 2014:9) rekommenderas att verktygen SARA, SAM, PATRIARK och eventuellt Check-10(+) ska användas nationellt. Utvärderingen bygger på en genomgång av 98 ärenden i vilka en riskbedömning med Check-10(+) genomfördes i Polismyndigheten i Uppsala län. Arbetssättet och verktyget studeras avseende den initiala bedömningen där ärenden som sedan går vidare till strukturerad bedömning sorteras ut, internt bortfall, rekommenderade och genomförda stöd- och skyddsåtgärder, återfall i brott samt fördelning av risknivåer. De ärenden som bedömdes med Check-10(+) var olika och inkluderade brottstyper som olaga hot, och misshandel men även mordbrand och utpressning för att nämna några. Det interna bortfallet var stort främst avseende faktorer som var associerade med gärningspersonen med det gemensamt att de rörde personlighetsrelaterade egenskaper som kriminell attityd, impulskontroll och bristande medkänsla. Bortfallet var så stort (mer än 30%) att instrumentets validitet var hotad. De flesta ärenden bedöms i mitten av den skala på vilken risken och hotbilden bedöms. Det vanligaste är att det föreligger viss risk eller risk och låg hotbild eller förhöjd hotbild (2 eller 3). Få ärenden bedöms som ringa risk eller ingen hotbild och antalet ärenden där risken bedöms som betydande och hotbilden som hög är mycket få. Antalet riskfaktorer stiger med risknivån och hotbildsnivån. Ju fler riskfaktorer som föreligger desto högre bedöms alltså risken och hotbilden. I knappt hälften av ärendena rekommenderas någon stöd- och/eller skyddsåtgärd och i ungefär en fjärdedel av det totala antalet ärenden genomfördes den rekommenderade åtgärden. De åtgärder som rekommenderas är i huvudsak samtal som innehåller information om brottsofferstöd och riskanalysens resultat, motiverande samtal (gäller främst vittnen), säkerhetssamtal och säkerhetsbesiktning av bostaden. Det är inte möjligt att identifiera något mönster i siffrorna. Oavsett risknivå rekommenderas åtgärder i ungefär hälften av ärendena. Oavsett allvarlighetsgrad i befarat återfall rekommenderas åtgärder i ca 40% av ärendena. Åtgärder på basen av rekommendationerna genomförs i ca 60% av fallen, också oavsett risk och allvarlighetsgrad. Det finns alltså inte någon systematik i detta och riskbedömningen styr inte åtgärdsrekommendationerna. Detta är den enda utvärdering av verktyget som hittills genomförts. Den viktigaste slutsatsen är därför att kunskapen om hur Check-10(+) fungerar i polisverksamhet måste öka innan verktyget rekommenderas som en nationell modell för bedömning av risk för generellt våld på individnivå. Resultaten från föreliggande utvärdering pekar på brister som måste åtgärdas och det bör föras en diskussion kring möjligheterna att bedöma risken för upprepat våld för så olika brottstyper som de som bedöms med verktyget i den här studien.

The HCR-20 is widely used to assess risk of violence among patients with schizophrenia. Further understanding of the accuracy and changes over time in C and R scores is needed. Using prospectively collected data on 248 men with schizophrenia, the present study found that the HCR-20 significantly predicted aggressive behavior over 24 months. The H, C, R, HCR-20 total, and final risk judgment scores were unable to predict aggressive behavior better than chance among the general psychiatric patients in the first six months after discharge. Changes in three C items, the total R score, and in three R items significantly predicted changes in aggressive behavior.

Objective: To examine annual weight-development in a sample of 215 psychotic patients treated with risperidone over 5 years.

Method: Naturalistic longitudinal study.

Results: The sample was more obese than the general population at baseline, but also increased much more in mean body mass index over approximately the same time period, while patients off medication seemed to remain weight stable. Excessive weight gain (>7%) was experienced by 40.2% and was weakly associated with weight at baseline (beta = -0.2%; P = 0.02), while independent of gender, symptoms, years of illness, prolactin levels and nicotine consumption. In patients with complete weight data (n = 87), approximately 72% (3.4 +/- 8.3 kg) of the observed 5 years weight gain (4.7 +/- 11.6 kg) had been accumulated after 2 years.

Conclusion: Antipsychotic drug treatment resulted in significant weight gain, which levelled off over time. Unfortunately, few significant predictors of adverse weight development could be identified, leaving little guidance for clinical decision making regarding this specific side-effect.

Objective To investigate the effect of second-generation antipsychotics on cognitive function in patients diagnosed with schizophrenia or schizoaffective disorder. Method Multiple-treatments meta-analysis model. Results On cognitive composite score, sertindole was superior to clozapine, effect size (ES) 0.87; 95% CI: 0.12–1.63, quetiapine, ES 0.75; 95% CI: 0.00–1.49, and first-generation antipsychotics (FGAs), ES 0.89; 95% CI: 0.14–1.64. Analyses on each cognitive domain showed clozapine, ES 0.37; 95% CI: 0.00–0.74, olanzapine, ES 0.31; 95%CI: 0.02–0.59, quetiapine, ES 0.34; 95% CI: 0.03–0.64, and FGAs, ES 0.51; 95% CI: 0.18–0.83 performing poorer on verbal working memory than ziprasidone, as well as FGAs performing poorer than risperidone, ES 0.31; 95% CI: 0.04–0.58. On executive function, sertindole performed better than clozapine, ES 0.82; 95% CI: 0.06–1.58, olanzapine, ES 0.81; 95% CI: 0.07–1.55, quetiapine, ES 0.76; 95% CI: 0.02–1.51, ziprasidone, ES 0.90; 95% CI: 0.14–1.67, and FGAs, ES 0.83; 95% CI: 0.08–1.58. On processing speed, FGAs performed poorer than sertindole, ES 0.97; 95% CI: 0.02–1.91, and quetiapine, ES 0.36; 95% CI: 0.01–0.72. On long-term verbal working memory, clozapine performed poorer than olanzapine, ES 0.41; 95% CI: 0.06–0.76. On verbal fluency, FGAs performed poorer than olanzapine, ES 0.26; 95% CI: 0.01–0.50, and clozapine, ES 0.44; 95% CI: 0.06–0.81. Lastly, FGAs, ES 0.41; 95% CI: 0.04–0.78, and clozapine, ES 0.44; 95% CI: 0.05–0.83, performed poorer on visuospatial skill compared to olanzapine. Conclusion The meta-analysis was able to detect some trends in the data analyzed, but did not show any drug having a uniform positive cognitive profile.

Objective: To assess the cognitive effects of sertindole augmentation in clozapine-treated patients diagnosed with schizophrenia. Cognition is secondary outcome of the trial. Method: A 12-week, double-blinded, randomized, placebo-controlled, augmentation study of patients treated with clozapine. Participants were randomized 1:1 to receive 16 mg of sertindole or placebo as adjunctive treatment to clozapine. Results: Participants displayed substantial cognitive deficits, ranging from 1.6 standard deviation below norms at baseline to more than three standard deviations on tests of response readiness and focused attention. There were no significant differences between sertindole augmentation and placebo groups at study end. Correlation analysis of Positive and Negative Syndrome (PANSS) subscales, Global Assessment of Functioning subscale (GAF-F) and Clinical Global Impression (CGI) with 20 neurocognitive indices was conducted, but no significant correlations were found. Second, we tested change from baseline to endpoint for the PANSS, GAF-F, and CGI, vs. the concomitant changes in cognitive test performance, and found no significant correlations. Conclusion: The clozapine-treated patients displayed marked cognitive deficits at baseline. Adding sertindole did not improve or worsen cognitive functioning, which is in line with previous negative studies of the effect on cognition of augmenting clozapine treatment with another antipsychotic drug.

Objective: To investigate the association between the Positive and Negative Syndrome Scale (PANSS) cognitive factors and cognition assessed by neuropsychological tests. Method: Ninety patients with a psychotic illness, the majority having a schizophrenia diagnosis, were assessed with PANSS ratings and tested by a comprehensive computerized neuropsychological test battery, EuCog. Results: Test performance was in the normal range for some of the cognitive indices, but substantially reduced for others, compared with norms, particularly speed-based indices. PANSS ratings were non-specifically associated with cognitive indices representing performance (speed and accuracy) and problem solving strategies (executive functions). There was no discriminant validity for the cognitive factor. A regression analysis suggested that the PANSS cognitive factors reflected verbal IQ but no other cognitive domain like memory, attention or speed. Conclusion: Cognitive test performance is associated with psychopathology as assessed by PANSS items but in a non-specific way. The PANSS cognitive subscale seems to reflect over-learned verbal skills rather than the cognitive domains, which are known to be specifically affected in schizophrenia and relevant for the prognosis. Consequently, PANSS ratings cannot replace the information inherent in neuropsychological test data. The extensive speed problem of patients with schizophrenia should be studied in more detail using test batteries that focus on that problem.

Drug attitude inventory (DAI-30) is considered to be the best predictor of poor adherence in first-episode schizophrenia. We compared the short version (DAI-10) with DAI-30 in long-term schizophrenia, documented if DAI was associated with poor insight, PANSS and GAF and constructed DAI-10 percentiles. DAI-30 and DAI-10 were homogenous (r = 0.82 and 0.72, respectively) with good test–retest reliability (0.79). The correlation between the DAI versions was high (0.94). Percentile scores of DAI-10 were computed. DAI is an easy-to-use self-report instrument seemingly assessing a unique clinical dimension relevant to non-adherence. DAI-10 might be preferred for its simplicity and good psychometric properties.

BACKGROUND: The objective was to identify separate cognitive domains in the standard assessment tools (MMSE, ADAS-Cog) and analyze the process of decline within domains during three years in Alzheimer's disease (AD) patients with donepezil treatment. METHOD: AD patients (n = 421) were recruited from a clinical multi-centre study program in Sweden. Patients were assessed every six months during three years. All patients received donepezil starting directly after study entry. After dropouts, 158 patients remained for analyses over three years. Data for the other patients were analysed until they dropped out (4 groups based on length in study). RESULTS: Factor analyses of all items suggested that there were three intercorrelated factors: a General, a Memory and a Spatial factor for which we constructed corresponding domains. Overall there was a cognitive improvement at six months followed by a linear drop over time for the three domains. Some group and domain differences were identified. Patients who remained longer in the study had better initial performance and a slower deterioration rate. The early dropouts showed no improvement at six months and many dropped out due to side effects. The other groups displayed a performance improvement at six months that was less pronounced in the Memory domain. Before dropping out, deterioration accelerated, particularly in the Spatial domain. CONCLUSION: The course of illness in the three domains was heterogeneous among the patients. We were not able to identify any clinically relevant correlates of this heterogeneity. As an aid we constructed three algorithms corresponding to the cognitive domains, which can be used to characterize patients initially, identify rapid decliners and follow the course of the disease.

Objective: The de-institutionalizing process came to an end before the millennium shift by closing mental hospitals. After that some of the most ill patients are cared for in sheltered housing (SH). There is no in-house psychiatric competence and the staff on the floor usually lacks such knowledge and training. Observation instruments may improve this by making it possible to assess and monitor patients. Method: FAST-O is a simple twelve-item observation scale. Staff at eight SH units were trained in using the instrument and then assessed a total of 67 patients once, twice or three times at monthly intervals. Results: Ten items formed two highly homogenous subscales reflecting Social skills (Soc) and Excitation/Aggression (E/A). Depression and Clinical Global Impression (CGI) items were considered separately. The correlation pattern suggested that the ratings had construct validity. A cluster analysis identified three patient subgroups, of which one had very high E/A scores. Comparisons with reference data suggested that the average symptom level was on par with acutely admitted in-patients for this subgroup. In all groups, E/A symptoms varied considerably over time, the other symptoms were more stable. There were marked differences among the eight SH units with respect to the level of patient problems. Conclusions: The SH staff was able to produce valid FAST-O assessments. There are reference data which makes it possible to characterize individual patients as well as SH units with respect to treatment needs and safety aspects (for instance risk of violence).

Objective: To analyze sex differences among adult, never-treated patients referred for central stimulant treatment of ADHD. Method: Data for 600 consecutive patients from northern Norway referred for evaluation by an expert team during 7 years were analyzed. General background information, diagnostic and social history, and symptom profiles were compared between previously never-treated men and women. Results: The sex ratio was skewed. Of the previously untreated patients, more than 20% fell outside society's ordinary vocational activities or social benefit system. Most patients had the combined form, one third the inattentive type, and only 2% the hyperactive/impulsive subtype. Abuse and criminality were more common among men, and affective, eating, and somatization disorders were more common among women. Otherwise few sex differences were found. Conclusion: AD/HD symptom intensity and subtypes did not differ between the sexes and was unrelated to age. Symptom intensity was linked with criminality, abuse, and other psychiatric problems, differentially for the two sexes.

Objective: The evidence for central stimulant (CS) treatment in ADHD is strong in some respects but not with respect to unselected clinical material and long-term effects over the life course cycle. The objective of this study was to explore differences in vocational, psychiatric, and social impairment, including crime and substance abuse, among adults with ADHD, treated or not, with CS drugs before age 18. Method: A clinical population of men (N = 343) and women (N = 129) seeking CS treatment as adults was assessed within a specific program for such treatment. Clinical information and data collected by structured instruments were available. Results: Previously CS-treated persons had a lower frequency of problems (alcohol/substance abuse, criminality), and of certain psychiatric disorders (depressive, anxiety and personality ones). Most differences were substantial. Conclusion: The study supports the assumption that CS treatment during childhood/adolescence offers some protection against the development of a range of problems known to characterize adult ADHD patients.

The self-report Drug Attitude Inventory (DAI), in 30- and 10-item versions, provides unique information of clinical relevance for monitoring treatment adherence among people diagnosed with schizophrenia. The primary purpose of this paper was to evaluate the 10-item version among patients living in sheltered housing. Data were collected among 68 persons living in sheltered housing, most of them (82%) diagnosed with schizophrenia, 6% with non-organic psychoses, and 12% with other diagnoses. The dichotomic response format of the original DAI-10 was replaced by a 4-point Likert scale, in order to improve the resolution of the scale. Over 90% of the participants produced meaningful scores. A factor analysis suggested a 2-factor orthogonal structure: one highly homogenous factor (5 items) reflected wanted effects of the drug and displayed a bimodal distribution; one factor (3 items) reflected side effects. One item concerned the perceived control over one's drug treatment, which is a key clinical issue. One item was conceptually ambiguous and displayed no correlations with the other items. On the basis of the results we suggest cut-off scores which indicate the need for three kinds of adherence-improving interventions. Summing up, by dropping one item and using a Likert scale response format, the resulting instrument, DAI-9, appears to be an easy-to-use self-report instrument for monitoring drug attitudes and to identify needs for treatment adherence interventions among seriously ill patients.

Intimate partner violence (IPV) is a global health problem with severe consequences. One way to prevent repeat IPVis to identify the offender’s risk of recidivism by conducting a risk assessment and then implement interventions to reduce the risk. In order to be effective, accurate risk assessments and effective interventions are required. Practitioners in different settings are conducting IPV risk assessments, but the predictive validity of practitioners’ IPV assessments has not been studied via a comprehensive literature search. This is the overall aim of the present study. The literature search was conducted in five different databases and at three different publisher sites. The selection of studies was based on nine different inclusion and exclusion criteria. The number of studies that fulfilled the criteria was unexpectedly small (N = 11). One of the studies was conducted in a treatment setting, the others in criminal justice settings. The predictive accuracy for the global risk assessments ranged from low to medium. The role of treatment or other interventions to prevent repeat IPV had been analyzed in one way or another in eight of the studies. There is a knowledge gap, the reasons of which are discussed.