The Canadian Journal of Psychiatry

To conduct a critical review of the literature on the matter of mental illness and violence, to examine whether there is enough evidence to establish a causal link, and to provide epidemiological background to measure the risk to the population.

Based on a computerized search of the literature on mental illness and violence previously conducted for Health Canada, studies in the area were critically reviewed and divided into 3 main categories: 1) studies of criminal and violent behaviour among psychiatric patients, 2) studies of psychiatric illness among offenders (prevalence studies in institutions, analytical studies, and community follow-up of offenders), and 3) epidemiological community-based studies on the issue of mental illness and violence (police-citizen encounters, representative samples, and other epidemiological studies). Causality rules andmeasures of risk were then applied to the evidence elicited.

The review of the literature suggests that only a small minority of hospitalized patients, typically those suffering from acute psychotic symptoms, are involved in violent incidents. Formerly hospitalized patients are at a higher risk of committing violence if they are not properly treated and are experiencing threat/control-override psychotic symptoms. Substance abuse disorders significantly raise the risk for violence. Family members are the most at risk of being victimized.

An association exists between mental illness and violence, but the many covariations that naturally affect the equation between them introduce uncertainties in establishing causality.

To discuss the ethical and legal imperatives to protect third parties from harm in circumstances often believed to be protected by doctor-patient confidentiality.

A review of recent legislative changes and legal decisions pertaining to a psychiatrist's duty to warn.

The current legislative and legal climate presents many risks to the concept of doctor-patient confidentiality. Psychiatrists must carefully consider any guarantees of confidentiality made to patients and must discuss the limits of confidentiality when obtaining consent for treatment.

To discuss the implications of recent legislative changes and court decisions in Canada that have placed the privacy of psychiatric records information at risk. New areas of exposure include client access to clinical information provided by family members, parental access to children's records, and court access to clinical records in civil, criminal, and family law matters.

A review of recent legislative changes and court decisions pertaining to access to psychiatric records.

At present, psychiatric records can no longer be regarded as confidential. Recent changes in the concept of privilege of treatment records necessitates several changes in psychiatric practice regarding informed consent to treatment, content of clinical records, and responses to demands for information.

The present study was undertaken to determine current attitudes and behaviour toward informed consent for antipsychotic medication and documentation of the informed consent process in patient charts.

Thirty psychiatrists treating a minimum of 10 patients on antipsychotic medication were selected from teaching and nonteaching hospitals. Clinicians completed questionnaires on their behaviour and attitudes regarding documentation of informed consent and antipsychotic medication. Physicians' charts were reviewed to ascertain documentation.

Psychiatrists reported sometimes documenting the informed consent process. The chart review revealed that, on average, each psychiatrist had documentation in 23% of charts. Physicians who either were affiliated with a teaching hospital or spent more time reading medical journals were more likely to document the informed consent process.

Physicians who use antipsychotic medication as a treatment in their practice are not routinely documenting the informed consent process in patient records. Physicians should pay more attention to this aspect of record keeping because it is their only record of the consent process.

Since most clinical trials of atypical antipsychotics have been conducted in hospitalized patients, a Phase-IV, multicentre, 8-week, open-label, flexible-dose study was performed to assess the efficacy and safety of risperidone in outpatients with schizophrenia.

Three hundred and thirty patients with a Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) diagnosis of schizophrenia were enrolled at 61 Canadian sites. Upon trial entry, the patients had their neuroleptic and antiparkinsonian drugs discontinued, and treatment with risperidone was initiated at a dose of 2 mg daily, then increased by 2 mg daily on each of the 2 following days until the initial target dose of 6 mg daily was reached on day 3. No further titration was allowed until day 14, after which the dose could be increased or decreased.

During the stabilization phase (days 14–56), the dose was unchanged in 44% of the patients, increased in 24%, decreased in 23%, and titrated both up and down in 9% of the patients. In the efficacy-evaluable population (n = 292), treatment with risperidone produced substantial (−26.4) and significant (P = 0.0001) improvement in the total Positive and Negative Syndrome Scale (PANSS) score. At the end of the study (week 8), 85% of patients were classified as clinically improved according to an a priori definition (that is, 20% or more decrease from baseline in total PANSS score). On their last study visit, 75% of patients reported their experience with risperidone as better than their previous neuroleptic therapy. Risperidone was generally well tolerated. The adverse events reported by more than 5% of the patients were insomnia, nausea, headache, somnolence, dizziness, fatigue, anxiety, vomiting, and ejaculation disorder. Seventy-four percent of the reported treatment-related adverse events were recorded during the first 2 weeks of the trial, possibly because of the discontinuation of prior neuroleptic and antiparkinsonian drugs followed by immediate upward titration of risperidone. However, only 8.5% of adverse events were reported to have occurred during week 3, and only 0.8% of adverse events were reported for week 8. Risperidone treatment produced significant improvements over baseline in the incidence and severity of extrapyramidal symptoms (EPS). A slight but statistically significant increase in body weight was observed.

The results of this open-label, Phase-IV trial in a large population of outpatients with schizophrenia found that risperidone was superior to the neuroleptics that patients had previously taken in terms of efficacy and severity of EPS. Our results suggest the use of risperidone at lower doses in outpatients with schizophrenia.

To evaluate the adequacy of the reports of methodological and statistical aspects of randomized, controlled trials that evaluate antidepressant medications and the degree to which their results can be used in subsequent metaanalyses.

Randomized, controlled trials published in English that compared 2 antidepressant drugs with a placebo were reviewed. Papers were located using Medline and reference lists.

Each paper was evaluated using a checklist, and 3 summary criteria scores were derived: minimal, ideal, and overall.

Only 9 of the 69 papers met the minimal criteria to be included in a metaanalysis (which would report the final sample size and an estimate of the mean and of the standard deviation); and 0 met all of the ideal criteria for reporting clinical trials. Out of a possible 100 points, the mean score for the articles was 51, and the highest score was 80. Scores were not related to the citation impact factor of the journal in which they appeared.

Researchers must become more aware of the criteria for reporting clinical trials, and editors must insist more strenuously that these criteria be satisfied.

To evaluate the relationships of symptoms of catatonic schizophrenia to 77 symptoms relevant for diagnosing schizophrenia and to socioanamnestic variables.

Data from a sample of 112 Canadian patients diagnosed with schizophrenia according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) were evaluated via φ correlation coefficients.

Forty-five (40.2%) of our 112 patients had catatonic symptoms, either at the time of this study or in the past. However, only weak correlations (φ < 0.31) to other symptoms relevant for diagnosing schizophrenia were found, and no significant correlations to socioanamnestic variables were found.

Symptoms of catatonia appear to be independent of the key symptoms of schizophrenia.

Chez les sujets psychotiques, l'abus de substances psychoactives est-il associé à l'adaptation sociale?

Cinquante-cinq hommes psychotiques provenant d'un centre de détention ou d'un hôpital psychiatrique ont été évalués à l'aide de l'Échelle d'adaptation sociale (EAS-II) et d'une version française de la Phillips Rating Scale of Premorbid Adjustment in Schizophrenia (l'échelle d'évaluation de l'adaptation prémorbide de la schizophrénie de Phillips).

Chez les sujets psychotiques, l'abus de substances psychoactives est associé à certains indices d'adaptation sociale et d'adaptation sexuelle prémorbide.

Des différences sont observées dans certains aspects du fonctionnement social, mais il est difficile de porter un jugement global sur l'adaptation sociale.

To test the hypothesis that adoptees are overrepresented among a sample of clinic-referred boys with gender identity problems (N = 238). To compare the adoptees and nonadoptees on demographic, behaviour problem, and gender-typed measures.

The percentage of clinic-referred boys with gender identity problems adopted in the first 2 years of life (“early adoptees”) was compared to the base rate of boys adopted in Ontario. Parent-report and behavioural measures were used to compare the early adoptees with “late adoptees” (adopted after the second year of life) and nonadoptees.

The percentage of boys with gender identity problems who were early adoptees (7.6%) was significantly higher than the base rate of males adopted in Ontario in the first 2 years of life (1.5%). Both the early and late adoptees were significantly less intelligent than the nonadoptees. The early adoptees also had significantly higher externalizing T scores on the Child Behavior Checklist than did the late adoptees and the nonadoptees. The 3 groups did not differ in the percentage who met the complete Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for gender identity disorder and on 4 other measures of gender-typed behaviour.

Adoptees are overrepresented among clinic-referred boys with gender identity problems. The reasons for this finding are not clear but may be accounted for by general risk factors that increase the likelihood of clinical referral or by psychosocial and biological factors associated with adoption.