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Homicide due to mental disorder in England and Wales
- Jeremy W Coid (31 October 2008)
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Homicide due to mental disorder
- David Vinkers, Marko Barendregt and Edwin de Beurs (31 October 2008)
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Homicide due to mental disorder
- Matthew M Large, Glen Smith, Olav Nielssen (27 November 2008)
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Jeremy W Coid, Professor of Forensic Psychiatry Barts and the London Medical School, Queen Mary University of
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j.w.coid{at}qmul.ac.uk Jeremy W Coid
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A conclusion in the abstract of Large et al (1) is illogical. If the same sociological factors causing increase in "other" homicides up until the 1970's had caused the increase among the mentally disordered, then they should have continued to have exerted this effect, with a continuing rise corresponding to "other" homicides instead of a fall. Similarly, if the subsequent decline in homicides among the mentally disordered were due to improvements in psychiatric treatment and service organisation as the authors suggest, then the rise in their rates prior to that period must have been due to the converse: a deterioration in quality of treatment and service organisation. The obvious explanation (which is now politically incorrect) is the closure of mental hospitals and rehabilitation at that time due to almost non-existent community care. In reality, it is highly unlikely that there has been a true rise and fall in homicide among mentally disordered persons in England and Wales over the past fifty years. These figures are entirely based on statistics which reflect the workings of the Criminal Justice system (a charge to which I plead guilty (2)). They merely reflect changes in processing defendants by the courts. The probable culprit for declining diminished responsibility was declining enthusiasm for treating personality disordered and sexually deviant killers under the Mental Health Act legal category "Psychopathic Disorder." The authors did not provide statistics on other forms of manslaughter. These have increased in recent years, suggesting that defence lawyers have become more successful in putting forward alternative defences to murder than diminished responsibility. I agree with the authors that sociological and legal factors (mainly the latter) have effects on rates of homicide due to mental disorder. But it is the overall base rate of homicide in the population that matters and with which these figures must be compared. This differs markedly between different countries. In those where it is very high, such as South America and Sub-Saharan Africa, mental disorder is almost irrelevant as an epidemiological risk factor. The authors refer to a small number of studies suggesting a correlation between rates of homicide amongst the mentally disordered and rates among the rest of the population. It may well be that the "laws" (2) they refer to are too rigid. For example, it makes sense that a country that allows handgun ownership is more likely to have killers with schizophrenia who use handguns, and at a rate higher than in countries where they are banned ? although the evidence for this remains thin on the ground. But from the public health perspective does it matter? Handguns are the key risk factor, not schizophrenia. England and Wales has a low but steadily rising rate of homicide. It is unrealistic to propose Mental Health services as a public health intervention, but will be popular with politicians. Social geographers have demonstrated that social exclusion and growing social inequalities are the strongest correlates with this phenomenon affecting young men in England and Wales (3). 1. Large, M., Smith, G., Swinson, N., Shaw, J., Nielson, O. Homicide due to mental disorder in England and Wales over 50 years. Br. J. Psychiatry 2008, 193: 130-133. 2. Coid, J. The epidemiology of abnormal homicide and murder followed by suicide. Psychol. Med 1983, 13: 855-860. 3. Shaw , M., Tunstall, H., Dorling, D. Increasing inequalities in risk of murder in Britain: Trends in the demographic and spatial distribution of murder, 1981-2000. Health & Place 2005, 11: 45-54. Jeremy W. Coid, St Bartholomew's Hospital, 61 Bartholomew Close, London, EC1A 7BE, UK Email: j.w.coid@qmul.ac.uk |
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David Vinkers, Psychiatrist Netherlands Institute of Forensic Psychiatry, Marko Barendregt and Edwin de Beurs
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d.vinkers{at}dji.minjus.nl David Vinkers, et al.
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To the editor, With great interest, we read the article of Large et al. in the August issue of The Journal. It describes the rise and fall in homicides attributed to mental disorders in England and Wales over the last 50 years1. Since 2000, the rate of homicide due to a mental disorder in England and Wales is 0.07 per 100.000 or lower. Encouraged by the authors, we examined the rate of homicides due to a mental disorder in the Netherlands. Dutch law considers responsibility for crimes to be diminished if there is a causal relationship between a mental disorder and the crime committed. Five degrees of responsibility are defined (i.e., complete responsibility, slightly diminished, diminished, considerably diminished, and total absence of responsibility). A severe psychiatric disorder, usually of a psychotic nature, is a necessary condition for a “total absence of responsibility” finding. From the 1212 cases of homicide between 1-1-2000 and 31-12-2006, 1020 (84.2 %) defendants were pre-trial psychiatric assessed. Of these, 58 (5.7 %) were considered to have complete absence of responsibility. Furthermore, 63 (6.2 %) were found to be strongly diminished responsible, 239 (23.4 %) diminished responsible, 309 (30.3 %) slightly diminished responsible, and 259 (25.4 %) complete responsible. A psychotic disorder was diagnosed in 115 (11.3 %) persons, which is in line with earlier studies in persons indicted for homicide2. The rate of homicide due to mental disorder would be 0.11 per 100.000 when persons with a complete absence or strongly diminished of responsibility are included. If persons with a diminished responsibility are also included, this would be 0.32 per 100.000. The difference between England and Wales and the Netherlands may be explained by a different view on the issues of a diminished responsibility3. This may also explain the rise and fall of homicides due to mental disorders in England and Wales over the last 50 years. 1. Large M, Smith G, Swinson N, Shaw J, Nielssen O. Homicide due to mental disorder in England and Wales over 50 years. Br J Psychiatry 2008; 193: 130-133. 2. Taylor PJ, Gunn J. Homicides by people with mental illness: myth and reality.Br J Psychiatry 1999; 174: 9-14. 3. Dell, S. The mandatory sentence and Section 2. J Med Eth 1986; 12: 28-31. |
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Matthew M Large, Psychiatrist St Vincent's Hospital, Sydney, Australia, Glen Smith, Olav Nielssen
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mmbl{at}bigpond.com Matthew M Large, et al.
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Dear Editor We welcome interest in our study of homicide in England and Wales [1, 2]. However, we disagree with Coid’s assertion that the conclusions are illogical because the same social factors that were associated with the increase in homicides by the mentally ill up to the 1970s were present when those homicides declined [1]. There are several possible reasons for decline in homicide by the mentally ill, including the availability of treatment. Coid’s assertion that a fall in homicide due to better treatment must mean that the earlier rise was due to deteriorating mental health services is a similar oversimplification. There has been no change in the law regarding diminished responsibility since 1957. Coid’s explanation that the decline in homicide by the mentally ill since the late 1970s was due to a change in the threshold for the verdicts of diminished responsibility is not supported by any data. Moreover, a change in threshold for diminished responsibility would not explain the decline in the verdicts of not guilty due to mental illness, permanently unfit for trial and infanticide. We also defend the use of legal outcomes to define cases. Given the careful attention paid to homicide matters by the courts, their verdicts are likely to be reasonably sensitive and highly specific [3]. Vinkers et al. report eight years’ data from the Netherlands, without showing that rates of homicide by the mentally ill have declined over a longer period [2]. However, a lack of a decline in the Netherlands might not be unexpected, as we have found that 40% of homicides in psychotic illness occur before treatment [3], that delay in the initial treatment of schizophrenia is associated with a greater proportion of homicides during the first episode of psychosis [4] and that jurisdictions with mental health laws that require a patient to be dangerous before they can receive involuntary psychiatric treatment, such as the Netherlands, have longer delays in the treatment of early psychosis [5]. We look forward to a challenge to our findings based on data rather than opinion and speculation. 1. Coid JW Homicide due to mental disorder in England and Wales. Br J of Psychiatry, 31 Oct 2008 http://bjp.rcpsych.org/cgi/eletters/193/2/130#22550 2. Vinkers D, Barendregt M, de Beurs E. Homicide due to mental disorder. Br J Psychiatry, 31 Oct 2008 http://bjp.rcpsych.org/cgi/eletters/193/2/130#22569 3. Nielssen O, Large M Rates of Homicide During the First Episode of Psychosis and After Treatment: A Systematic Review and Meta-analysis Schizophrenia Bulletin 2008; doi: 10.1093/schbul/sbn144 4. Large M, Nielssen O. Evidence for a relationship between the duration of untreated psychosis and the proportion of psychotic homicides prior to treatment. Soc Psychiatry Psychiatr Epidemiol. 2008 ;43 :37-44. 5. Large M, Nielssen O, Ryan C, Hayes R. Mental health laws that require dangerousness for involuntary treatment may delay the initial treatment of schizophrenia. Social Psychiatry and Psychiatric Epidemiology 2008; 43 :251- 256 DR MATTHEW LARGE1 B.Sc (Med), MB.BS., FRANZCP DR GLEN SMITH 2 B.Sc (Hons) MB. BS. DR OLAV NIELSSEN1,3 MB. BS., M Crim., FRANZCP 1. Mental Health Services, St Vincent's Hospital, 299 Forbes Street, Darlinghurst, Sydney, NSW, 2010, Australia 2. Northern Sydney Central Coast Area Health Service, Macquarie Hospital, North Ryde, NSW, 2112 3. Clinical Research Unit for Anxiety Disorders, School of Psychiatry, UNSW at St Vincent's Hospital, 299 Forbes Street, Darlinghurst, Sydney, NSW, 2010, Australia Correspond with Dr Large. Email: mmbl@bigpond.com Declaration of interests The authors have no conflict of interests to declare. |
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