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© 2022 Taiwanese Journal of Psychiatry (Taipei) | Published by Wolters Kluwer - Medknow 39
Brief Report
Introduction
A consensus has yet to be reached on the association
between criminal behavior and mental illness [1]. The notion
that people with severe mental illness can be dangerous might
have been mediated through previous contacts or information
access [2]. Under varying law enforcement and socioeconomic
conditions, about 20%–40% of patients with severe mental
illness have a contact with the police at least once in their
lifetime; furthermore, more than 50% of police ocers have
reported receiving calls involving mentally ill individuals
at least once a month, and the reported issues are involved
disruptive behavior, violence, or substance use [3].
Clinicians suggested that for offenders with mental
illness (OMI), the role of mental health system should not
be completely replaced with the criminal justice system [4].
Some nations adopt secure hospital care for those OMI, the
cost of which can be higher than that of incarceration [5]. But
repeated oenders are less prevalent among patients discharged
from secure hospitals than released prisoners, implying that
changeable factors can be amended through mental health
interventions [5]. In Taiwan, according to the Criminal Code
of the Republic of China Article 87, those oenders with
mental illness can be committed to psychiatric hospitals for
custodial protection after execution of the punishment. But
a study showed that a half of those oenders with mental
illness are prosecuted again within three years of discharge
from psychiatric hospitals [6]. The possible factors associated
with recidivism among those with mental illness have been
previously reviewed as male gender, younger age upon rst
appearing in the court, substance use, personality disorder, or
family dysfunction [5,7]. To reduce the rates of recidivism and
Psychiatric Evaluations in Offenders with Mental Illness:
A Case Series
Chia-Heng Lin, M.D.1, Wen-Ching Hsieh, M.S.2, Heng-Wei Liu, B.S.1, Chia-Hsiang Chan, M.D., MSc.1,3*
Departments of 1General Psychiatry and 2Psychology, Taoyuan Psychiatric Center, Ministry of Health and Welfare, 3Department of Psychology, Chung Yuan Christian
University, Chung-Li, Taoyuan County, Taiwan
Background: The relation between mental illness and criminal oenses is controversial. In Taiwan, oenders with mental illness may be
sentenced to custodial protection. Nevertheless, the recidivism rates remain high in such populations. Factors associated with recidivism among
those oenders warrant further exploration. Methods: We retrospectively identied ve persons with mental illness who had repeated forensic
psychiatric evaluation for at least three times through reviewing forensic psychiatry records over the past decade at a psychiatric center. The related
sociodemographic characteristics and psychiatric proles in the 22 oenses were also collected and correlated with verdicts. Results: Those
ve oenders had family and personal histories of mental illnesses. They were relatively young at the rst oense and unemployed, unmarried
during the period of committing the oenses. Some oenders had a history of substance use, self-harm attempts, other criminal behaviors,
and poor adherence to treatments before the oense. All the concluded characteristics of forensic psychiatric evaluations were consistent with
the court judgments. Conclusion: Social dysfunction, poor adherence to treatments, history of substance use, and previous criminal records
were prominent among those ve repeated oenders.
Key words: criminal oense, custodial protection, mental illness, recidivism
Taiwanese Journal of Psychiatry (Taipei) 2022; 36: 39-43
1*Corresponding author. No. 71, Longshou Street, Taoyuan District,
Taoyuan 330, Taiwan.
E-mail: Chia-Hsiang Chan <cscott1125@gmail.com>
Access this article online
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DOI:
10.4103/TPSY.TPSY_5_22
How to cite this article: Lin CH, Hsieh WC, Liu HW, Chan CH. Psychiatric
evaluations in oenders with mental illness: A case series. Taiwan J
Psychiatry 2022;36:39-43.
© 2022 Taiwanese Journal of Psychiatry (Taipei) | Published by Wolters Kluwer - Medknow
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Abstract
Received: Oct. 15, 2021 revised: Nov. 23, 2021 accepted: Nov. 25. 2021
date published: Mar. 26, 2022
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Lin, et al.: Psychiatric evaluations in OMI
40 Taiwanese Journal of Psychiatry (Taipei) Volume 36, Issue 1, January-March 2022
develop individualized intervention programs for oenders
with mental illness (OMI) in Taiwan, the characteristics and
risk factors associated with domestic OMI samples warrant
exploration.
Here, we present ve persons with mental illness who had
repeated psychiatric evaluation, referred by the courts over the
past decade. The association of mental illnesses with criminal
behavior has been ascertained through reviewing forensic
psychiatric evaluation reports.
Methods
We reviewed the forensic evaluations of 700 criminal
cases referred to the Taoyuan Psychiatric Center (TYPC)
from October 2009 to January 2021. Most of those cases were
referred to the TYPC by the Taiwan Taoyuan District Court.
Two well-experienced forensic psychiatrists were included in
each interview for diagnostic validation using the Diagnostic
and Statistical Manual of Mental Disorders, Text Revision
(DSM-IV-TR), or DSM-5 for all oenders.
Sociodemographic data and clinical proles including
gender, birth date, identication number, educational years,
childhood adversity, job status, onset of psychiatric symptoms,
age of rst psychiatric visit, previous admissions, previous
mainline medications, and adherence to treatments before
oense were collected retrospectively from medical records at
the TYPC; we also correlated with the descriptions in forensic
evaluation reports. The details of the oense, symptoms upon
the oense, substance use before the oense, criminal history,
diagnoses, and inferred mental status upon the oense were
reviewed and collected from forensic evaluation reports. The
court decisions of the mental status upon the oense in each
criminal case were conrmed if publicly available verdicts
online in Law and Regulations Retrieving System of Judicial
Yuan. In the process of organizing the above information, we
identied ve repeated oenders with mental illness based
on the identication number, who received at least three
times of forensic evaluations during the past decade due to
dierent oenses. The study protocol was approved by the
institutional review board of the TYPC (IRB protocol number
= B20210722-2, and date of approval = September 6, 2021)
with the waiver of obtaining signed informed consents from
those patients.
Results
We identied ve persons with mental illness who had
repeated psychiatric evaluations (Table 1) for at least three
times in the TYPC. Four of them were men. The mean age at
initial oense and that at subsequent oenses after forensic
psychiatric evaluations were 20.2 and 36.3 years, respectively.
We observed the mean education years to be 12.4 years. Of the
repeated oenders, four were victims of childhood adversities.
All repeated oenders with mental illness were unemployed
and unmarried, and two of them lived alone around the time
of committing the oenses. All had familial and personal
histories of psychiatric illnesses. Moreover, three of them had
substance (including glue, ketamine, and amphetamine) use
disorders. Four had a history of violence, and three of them
had attempted suicide.
Table 2 lists 22 oenses made by the identied repeated
oenders with mental illness and the corresponding clinical
presentations. Most of the patients showed poor adherence to
medical treatment for months before committing their oenses.
Two oenses occurred in jail. About a half of the oenses
were involved theft. Of the 22 oenses (Table 2), four were
related to concurrent substance intoxication and to psychotic
symptoms. But 10 oenses were not directly related to active
psychotic symptoms. The remaining eight offenses were
related to positive psychotic symptoms and were considered
to be associated with diminished responsibility. All summaries
drawn from the forensic evaluations were consistent with court
verdicts. Oenders in only 2 of the 22 cases were sentenced
to custodial protection, but they made another oense before
the execution of the sentence.
Discussion
As shown in Table 1, we report the cases of ve repeated
oenders with mental illness who were referred to forensic
psychiatric evaluation by the courts. We identied some
features of those oenders that require clinical and public
attention. First, recidivism was frequent in those ve oenders,
with a median interval of 1.2 years. Second, the identied
oenders had a familial and personal history of mental illness
along with poor social support and nonadherence to medical
treatment around the time of commitment of oenses. Third,
the problems associated with the oenders, including substance
use, occupational dysfunction, and social dysfunction,
were unresolved even after serving the sentences. For the
ve oenders, systematic surveillance by family members,
judiciary systems, or clinical practitioners might not be
eective in preventing recidivism. Finally, the conditions
of self-harm attempts among them could not be neglected,
highlighting the importance of evaluation of suicide risk among
those oenders with mental illness.
A systemic review and meta-analysis revealed that the
worldwide pooled prevalence of psychotic disorders in male
prisoners was about 3.6%, higher than that in the general
population [8]. But a substantial proportion of prisoners with
schizophrenia does not receive treatment during incarceration,
and in England, where prisoners are monitored with extensive
support from the community, less than a quarter of prisoners
with psychotic disorders efficiently received community
mental health care [9,10]. If oenders with mental illness
are released into the same stressful environments without
enough support, adverse conditions such as homelessness,
substance use, and chaotic interpersonal relationship can
trigger the relapse of mental illness and recidivism [5,7]. To
general psychiatric units or community services alone, it has
been challenging to stabilize those repeated oenders with
complicated disadvantages.
In Japan, OMI had been treated in general psychiatric
hospitals along with other patients until 2003, when the
Medical Treatment and Supervision Act (MTSA) was passed.
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Lin, et al.: Psychiatric evaluations in OMI
41
Taiwanese Journal of Psychiatry (Taipei) Volume 36, Issue 1, January-March 2022
After the legislation of the MTSA, Japanese facilities for
oenders with mental illness collaborated with rehabilitation
coordinators to eectively reduce recidivism rates [11]. In
the United States, Forensic Assertive Community Treatment
programs are being implemented; such programs primarily
involve the delivery of comprehensive health-care services
to address untreated illnesses and establishment of criminal
justice agencies to prevent homelessness or imprisonment [12].
Coordination between assertive community intervention and
legal leverage is essential, partially because those oenders
with mental illness may ultimately need to stay on continued
medication to remain asymptomatic [13]. Nevertheless,
recidivism is not always directly related to the oenders’
mental illness [14].
A previous study revealed that compared with prisoners
without mental illness, prisoners with severe mental
illness tended to be imprisoned again within 18 months
of release [15]. Another study demonstrated that eective
predictors of recidivism are young age, early age of oense
onset, and a concurrent diagnosis of personality disorder [5].
If an oender has a co-occurring substance use disorder, the
recidivism rates can increase substantially [16]. A British
prospective cohort study reported that the recidivism rate
for those oenders with mental illness is about 15% within
2 years of discharge from secure hospitals; this is strongly
related to previous oenses, most of which are involved
sexual abuse or substance use problems [17]. Furthermore,
another long-term cohort study including 550 repeated
oenders indicated that 32% of the oenders eventually
committed suicide, 49% of those discharged are convicted
again, and nearly two-fth of the oenders are admitted into
secure hospitals again within 20 years of follow-up [18],
implying that the possible “static” risk factors are mediated
the long-term criminogenic tendencies in the oenses among
those repeated oenders [5].
Study Limitations
According to our review of the literature, our study is
among the few Asian studies concentrating on recidivism
among oenders with mental illness. Nevertheless, our study
has three limitations:
• Our cases were selected from oenders referred for forensic
evaluations, which may have excluded those who reached
settlements or applied for summary judgments. Not all
oenders with suspected mental health problems were
referred for forensic evaluations by the courts. Therefore,
we need to question about the representations of those
patients in this study.
• The offenders were forensically and psychologically
evaluated a couple of months after the actual events of
oense and occasionally received interventions from the
sta of the mental health system. The recall bias or external
incentives from the oenders during evaluations could not
be neglected [19].
Table 1. Sociodemographic data of five offenders with mental illness
Case number 1 2 3 4 5
Gender Female Male Male Male Male
Education years 17 12 14 8 11
Childhood adversity No Emotional neglect Homelessness Physical abuse Congenital facial
anomaly
Job status Unemployed Unemployed Unemployed Unemployed Unemployed
Marital status Single Single Single Single Divorced
Family history Inhalant use,
psychosis
Bipolar disorder Mood
disorder
Alcohol use Depression
Psychiatric history Depression Bipolar disorder Bipolar
disorder
Amphetamine use Bipolar disorder
Onset of psychiatric symptoms 22 28 19 19 40
Age of rst psychiatric visit, years 27 28 19 19 42
History of substance use Alcohol Alcohol, ketamine, cannabis,
amphetamine
No Alcohol,
amphetamine
Alcohol, glue
amphetamine
History of violence Ye s Ye s No Yes Yes
History of self-harm Yes Ye s Yes No Yes
Family support Poor Poor Poor Poor Poor
Admission from 2009-2021 Never 15 times Never 4 times 3 times
Previous mainline regimen Unknown Quetiapine, risperidone, olanzapine,
sulpiride, valproate, lithium
Unknown Risperidone,
olanzapine,
sertraline
Risperidone,
lithium
Age of rst oense, years 24 16 22 18 21
Criminal history Theft Theft, forgery Theft No Theft, obstructing
ocial duties
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Lin, et al.: Psychiatric evaluations in OMI
42 Taiwanese Journal of Psychiatry (Taipei) Volume 36, Issue 1, January-March 2022
Table 2. Twenty-two offenses of five offenders with mental illness repor ted after forensic psychiatric assessments
Case
number
Age of
offense
Offense§Adherence
before offense†
Symptoms upon
offense
Substance use
before offense
Diagnosis MSO
conclusion‡
Court
decision‡
1 30 T I Disorganized thought No Depressive disorder
suspected schizophrenia
D D
31 T I Disorganized thought No Depressive disorder
suspected schizophrenia
D D
Criminal
commitment
31 T I No No Psychotic disorder
suspected schizophrenia
F F
32 T R No No Depressive disorder
Psychotic disorder
F F
2 36 O I Disorganized thought
Manic symptoms
Alcohol
Ketamine
Ketamine abuse Bipolar
disorder
D D
36 E I Disorganized thought
Manic symptoms
Persecutory delusions
Alcohol
Ketamine
Ketamine abuse Bipolar
disorder
D D
36 T I Disorganized thought
Manic symptoms
Alcohol
Ketamine
Ketamine abuse Bipolar
disorder
D D
36 E I Disorganized thought
Manic symptoms
Alcohol
Ketamine
Ketamine abuse Bipolar
disorder
D D
39 E I Manic symptoms
Persecutory delusion,
Aditory hallucination,
Disorganized thought
No Bipolar disorder
Alcohol use disorder
Ketamine use disorder
Unable to
assess
Suspension
3 22 H I No No Bipolar disorder F F
24 O R Persecutory delusion,
Disorganized thought
Auditory hallucination
No Schizophrenia D D
27 O R Persecutory delusion
Disorganized thought
No Schizophrenia D D
4 36 T I Persecutory delusion
Disorganized thought
Auditory hallucination
No Schizophrenia D D
40 T R Disorganized thought No Schizophrenia
Amphetamine abuse
D D
40 T R Disorganized thought No Schizophrenia
Amphetamine abuse
D D
5 42 S I No No Bipolar I disorder F No open trial
43 S I No No Bipolar disorder
Inhalant use disorder
Borderline intellectual
disability
D No open trial
43 S I No No Bipolar disorder
Inhalant use disorder
Borderline intellectual
disability
F No open trial
43 A R No No Depressive disorder
Glue abuse, Alcohol
abuse
F F
Contd...
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Lin, et al.: Psychiatric evaluations in OMI
43
Taiwanese Journal of Psychiatry (Taipei) Volume 36, Issue 1, January-March 2022
Table 2. Contd...
Case
number
Age of
offense
Offense§Adherence
before offense†
Symptoms upon
offense
Substance use
before offense
Diagnosis MSO
conclusion‡
Court
decision‡
43 T I No No Bipolar disorder
Substance abuse
Borderline intellectual
disability
D D
44 D I No No Bipolar disorder
Substance abuse
Borderline intellectual
disability
D D
Criminal
commit-
ment
44 T I No No Bipolar disorder
Substance abuse,
Borderline intellectual
disability
D D
§A, abrupt taking; D, damage of property; E, extortion; H, homicide; O, obstruction of ocial duties; S, sexual assault; T, theft. †R, regular; I, irregular.
‡F, full responsibility; D, diminished responsibility. MSO, mental status at the time of oense
• Some individuals with disturbing behaviors or misdemeanors
might be sent to psychiatric treatment instead of being
prosecuted eventually. Experts may underestimate the
influence of mental illness on individuals committing
oenses.
Summary
Among the identied ve oenders with mental illness in
our study, they were younger in age at the rst oense, poor
social support, substance use, previous criminal records,
and poor adherence to treatment were clinically prominent
and characteristic. The present study can provide valuable
information for mental health professionals, legal department
sta, and policymakers in developing further research on
integrated strategies for reducing recidivism among oenders
with mental illness.
Financial Support and Sponsorship
None.
Conflicts of Interest
The authors declare no conicts of interest in writing this
report.
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