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Criminal behaviors and substance use disorder
in psychiatric patients
Francesco Achilli
1
, Silvia Leo
1
, Beatrice Benatti
1,2
, Alice Frediani
1
,
Maddalena Cocchi
1
, Laura Molteni
1
, Eleonora Piccoli
1
, Monica Lana
1
,
Emma Lucchini
1
, Dario Gobbo
1
and Bernardo M. Dell’Osso
1,2,3
1
Department of Psychiatry, Luigi Sacco University Hospital, Milan, Italy;
2
CRC “Aldo Ravelli”for Neuro-Technology
and Experimental Brain Therapeutics, University of Milan, Milan, Italy and
3
Department of Psychiatry and Behavioral
Sciences, Bipolar Disorders Clinic, Stanford University, Stanford, CA, USA
Abstract
Objective. People with mental illness are overrepresented throughout the criminal justice
system. In Italy, the Judicial Psychiatric Hospitals are now on the edge of their closure in favor
of small-scale therapeutic facilities (REMS). Therefore, when patients end their duty for criminal
behaviors, their clinical management moves back to the outpatient psychiatric centers. Elevated
risks of rule-violating behavior are not equally shared across the spectrum of psychiatric
disorders. To broaden the research in this area, we analyzed sociodemographic, clinical, and
forensic variables of a group of psychiatric patients with a history of criminal behaviors,
attending an outpatient psychiatric service in Milan, focusing on substance use disorder (SUD).
Methods. This is a cross-sectional single center study, conducted from 2020. Seventy-six
subjects with a history of criminal behaviors aged 18 years or older and attending an outpatient
psychiatric service were included. Demographic and clinical variables collected during clinical
interviews with patients were retrospectively retrieved from patients’medical records. Appro-
priate statistical analyses for categorical and continuous variables were conducted.
Results. Data were available for 76 patients, 51.3% of them had lifetime SUD. Lifetime SUD was
significantly more common in patients with long-acting injectable antipsychotics therapy, a
history of more than 3 psychiatric hospitalizations, and a history of previous crimes, particularly
economic crimes. Additionally, this last potential correlation was confirmed by logistic regression.
Conclusions. Data emerging from this survey provide new information about offenders with
lifetime SUD attending an Italian mental health service. Our preliminary results should be
confirmed in larger sample sizes.
Introduction
People with mental illness are overrepresented throughout the criminal justice system.
1
Mental
illness as a concept holds no exact definition, being grounded in psychiatry and representing
psychiatric disorders that are considered both medical and social problems, while definitions of
crime and violent offenders are offered by criminal justice institutions. Explanations of the two
concepts originate from quite opposite fields and come with different goals: psychiatry provides
treatments and law provides justice and social rehabilitation.
2
Additionally, taking into account
criminal responsibility in psychiatric offenders’cases, this is regularly assessed and an individ-
ual’s classification as dangerous can be renewed or removed by the courts. If the latter, the person
goes back into the community and standard mental health care is provided by community
mental health services.
3
A model of care for psychiatric patients that is partlydifferent from the rest of Europe has been
developedin Italy from 1978. Psychiatric hospitals were closed,and greater emphasis was placed on
social interventions, supporting the hypothesis that modifying certain environmental factors
would reduce relapse.
4
In the last three decades, there were several measures which moved to a
deinstitutionalization of psychiatric facilities and designed new methods for the management of
psychiatric patients with criminal behaviors. A significant step was made in 2008 with the shift of
psychiatric administration from the Ministry of Justice to the Ministry of Health. It followed the
total closure of forensic psychiatric hospitals (OPGs) in Italy and the conversion to a care model
based on residential units in the community (REMS), fully integrated in public mental health
services which were prescribed by law (L. 9/2012).
5
Law 81/2014 also stated that a patient cannot
stay in a REMS for a period longer than the prison sentence for the same index offense (L. 81/
2014).
6
Similarly,in Croatia and Portugal, psychiatric detention is limitedto the amount of time the
patients would have spent if they had not been mentally ill and had been givena jail sentence.
7
The
other EU countries allowthe imprisonment of mentally disordered offenders for longer periods of
time than the regular sentence.
8
CNS Spectrums
www.cambridge.org/cns
Original Research
Cite this article: Achilli F, Leo S, Benatti B,
Frediani A, Cocchi M, Molteni L, Piccoli E, Lana
M, Lucchini E, Gobbo D, and Dell’Osso BM
(2024). Criminal behaviors and substance use
disorder in psychiatric patients. CNS
Spectrums
https://doi.org/10.1017/S1092852924000373
Received: 06 March 2024
Accepted: 23 May 2024
Keywords:
Criminal behaviors; crimes; substance use;
antipsychotics; psychiatric hospitalization;
long-acting injection
Corresponding author:
Francesco Achilli;
Email: francesco.achilli@unimi.it
F.A. and S.L. are equally first authors.
© The Author(s), 2024. Published by Cambridge
University Press. This is an Open Access article,
distributed under the terms of the Creative
Commons Attribution licence (http://
creativecommons.org/licenses/by/4.0), which
permits unrestricted re-use, distribution and
reproduction, provided the original article is
properly cited.
https://doi.org/10.1017/S1092852924000373 Published online by Cambridge University Press
Therefore, when patients end their duty for criminal behaviors,
their clinical management moves back to the outpatient psychiatric
centers. High rates of psychiatric disorders in correctional facilities
have fueled widespread concerns about the “criminalization of
mental illness.”However, elevated risks of violent behavior are
not equally shared across the spectrum of psychiatric disorders.
In the past years, multiple studies in the field of forensic psychiatry
confirmed a close relationship between violent offenders and
comorbid substance use. There is consistent evidence that, partic-
ularly in combination with a comorbid substance use disorder
(SUD), mental disorders may contribute to the likelihood of vio-
lence and offending for part of the population.
9
Recent literature
has observed that acute substance use may be influential on behav-
ior by disinhibiting controls, increasing antisocial behaviors and
violence and that psychiatric or psychological exacerbation due to
SUD, intoxication, withdrawal, and dependence may increase the
likelihood of offending behavior.
10
In 2013, 110 international studies reporting factors associated
with violence were analyzed: violence was very strongly associated
with a history of polysubstance misuse (OR = 10.3) and strongly
associated with a diagnosis of comorbid SUD (OR = 3.1).
11
Research also showed that patients who suffer from schizophrenia
and concomitant substance use are not only more likely to expe-
rience a variety of psychosocial difficulties, such as violence, vic-
timization, incarceration, homelessness, and family difficulties, but
also are highly prone to adverse consequences, including poor
treatment response, relapse, hospitalization, HIV infection, hepa-
titis C infection, and suicide.
12
Moreover, patients with a psychiatric diagnosis and no absti-
nence during the follow-up or with a mental and behavioral
disorder due to psychoactive substance use showed more often
criminal recidivism than patients without such a disorder.
13
As regards the Italian forensic psychiatric system, few studies
were conducted in Italian centers. One of the variables associated
with violent behavior in patients in Italian public and private acute
psychiatric inpatient facilities was SUD.
14
This was also confirmed
by another study showing that aggressive patients were more likely to
have used substances in the past (43.0% vs. 31.6% in nonaggressive
group). This study also reported that hostile and violent patients
were more frequently hospitalized in public versus private facilities.
15
Furthermore, in a study on female patients who were discharged
from a REMS in Castiglione Delle Stiviere (Italy) before 2008 and
readmitted in the same place from 2008 to 2018, the readmission
was positively associated with the presence of SUD and a primary
diagnosis of personality disorder.
4
Furthermore, on a sample
including all patients admitted in Volterra (Italy) REMS from
2015 to 2017, the most frequent lifetime comorbid psychiatric
diagnosis was substance-related disorder (54.1%). Almost two-
thirds of those patients were already followed up by mental health
services before committing the crime. In that sample, SUDs were
the main psychiatric comorbidity and resulted more frequent in
bipolar patients than in other patients.
16
In the still growing field of forensic psychiatry, we aimed at
characterizing a sample of psychiatric patients who were also
offenders, focusing on the role of substance use in the social and
psychopathological picture.
Methods
Patients with a history of crimes, previous security measures, and/
or with ongoing investigation of either gender or any age attending
one community mental health center of the Azienda Socio Sanitaria
Territoriale Fatebenefratelli Sacco based in Milan, Italy, were
recruited. The inclusion criteria were the following: a confirmed
psychiatric diagnosis based on the Diagnostic and Statistical Man-
ual of Mental Disorders (DSM-IV-TR, DSM-5, or DSM-5-TR,
according to the manual in use at the time of the diagnosis) and
an age between 18 and 75 years at the time of recruitment; no
exclusion criteria were applied.
All medical records of recruited patients were retrospectively
reviewed, anonymized, and held in a secure database according to
the local data protection policies. Patients gave their written
informed consent to participate in this study and to have their
personal, clinical, and demographic data used for research pur-
poses. The present study was conducted according to the principles
expressed in the Declaration of Helsinki (PMC2566407).
Outcome measures
Main clinical and sociodemographic variables were collected
reviewing patients’medical records. Sociodemographic variables
included sex, presence of a partner, education level, and employ-
ment; clinical variables were diagnosis (psychosis, personality
disorder, depressive disorder, bipolar disorder, anxiety disorder,
obsessive–compulsive disorder, cognitive impairment, cognitive
decay, pathological gambling, eating disorder, attention deficit
hyperactivity disorder, lifetime and current alcohol use disorder
[AUD], lifetime and current SUD, and presence of a psychiatric
comorbidity), prescribed drugs (mood stabilizers [valproate, lith-
ium, lamotrigine, gabapentin, and pregabalin], first-generation
antipsychotics [FGA], and/or second-generation antipsychotics
[SGA]), prescription of long-acting injection (LAI) therapy, num-
ber of hospitalizations (sample was stratified by less than 4 or 4 or
more hospitalizations), and other medical comorbidities; we col-
lected the following forensic variables: type of committed crimes
(economic crime and/or violence against others), presence of past
history of crimes, previous security measures, previous incarcera-
tion, and if the current measure was a confinement in REMS. The
sample was divided into 2 main groups: patients with and without a
history of SUD (present and/or lifetime). AUD was considered
separately given its high frequency in psychiatric patients with
psychosis spectrum syndrome
17
and the underlining different
neurocircuits involved compared to other SUDs.
18
Those sub-
groups were then compared in order to find potential differences.
Statistical analyses
Patients’sociodemographic, clinical, and forensic characteristics
are presented using descriptive statistics (Table 1). χ
2
test for
dichotomous variables were performed to compare patients with
and without a lifetime substance use (Tables 2–6). Nonparametric
Mann–Whitney U test was used for continuous variables, compar-
ing patients with and without lifetime SUD. We used logistic
regression to analyze lifetime SUD as an independent variable.
Dependent variables analyzed were sex, presence of a partner,
education level, and employment. Furthermore, we investigated
the following clinical features: diagnosis (psychosis, personality
disorder, depressive disorder, bipolar disorder, anxiety disorder,
obsessive–compulsive disorder, cognitive impairment, cognitive
decline, pathological gambling, eating disorder, attention deficit
hyperactivity disorder, lifetime and current AUD, lifetime and
current SUD, and presence of a psychiatric comorbidity), pre-
scribed drugs (mood stabilizers [valproate, lithium, lamotrigine,
2 F. Achilli et al.
https://doi.org/10.1017/S1092852924000373 Published online by Cambridge University Press
gabapentin, and pregabalin], FGA, and/or SGA), prescription of
LAI therapy, number of hospitalizations (sample was stratified by
less than 4 or 4 or more hospitalizations), and other medical
comorbidities; other variables analyzed were type of committed
crimes (economic crime and/or violence against others), presence
of past history of crimes, previous security measures, previous
incarceration, and if the current measure was a confinement in
REMS. A p-value ≤0.05 was considered statistically significant.
Statistical analyses were performed using IBM SPSS Statistics
V26.0 (IBM Corporation, Armonk, NY, USA).
Results
Main sociodemographic and clinical data are summarized in
Table 1.
A total of 76 subjects were considered for this study. The mean
age was 48.7 ± 14.6 years, the mean age of illness onset was
27.9 ± 13.8 years,and the mean illness durationwas 20.4 ± 13.3 years.
Nine (11.8%) individuals were females, 17.1% had a partner, and
22.4% had a job or were retired. The most represented diagnoses
were psychosis (48.7%) and personality disorders (47.4%); 71.1% of
subjects had at least one psychiatric comorbidity, 51.3% subjects
used substances of abuse throughout life and 31.6% alcohol, 25.0%
had AUD when they committed the crime, and 31.6% had current
SUD. The most frequent offense was violence against others (60.5%),
Table 1. Descriptive Statistics: Main Sociodemographic Variables
Variables n(prevalence %) (mean ± DS)
Age 48.7 ± 14.6
SEX
Male 66 (86.8%)
Female 9 (11.8%)
Missing 1
EDUCATIONAL LEVEL
Middle school or lower 42 (55.3%)
High school or higher 28 (36.8%)
Missing 6
MARITAL STATUS
Single 59 (77.6%)
Married/engaged/widow 13 (17.1%)
Missing 6
ETHNICITY
Caucasian 66 (86.8%)
Other 10 (13.2%)
Missing –
EMPLOYMENT
Employed 56 (73.7%)
Unemployed/retired 17 (22.4%)
Missing 3
FAMILY HISTORY OF PSYCHIATRIC
DISORDERS
No 15 (19.7%)
Yes 5 (6.6%)
Missing 56
Table 2. Sociodemographic Variables
Variables
Lifetime
SUD
Absence of
lifetime SUD
p-valuen(%) n(%)
SEX 0.13
Male 35 (89.7%) 11 (73.3%)
Female 4 (10.3%) 4 (26.7%)
Missing ––
EDUCATIONAL LEVEL 0.60
Middle school or lower 23 (59.1%) 7 (46.7%)
High school or higher 14 (35.9%) 6 (40.0%)
Missing 2 2
MARITAL STATUS <0.05*
Single 34 (87.2%) 10 (77.6%)
Married/engaged/
widow 4 (10.3%) 5 (17.1%)
Missing 1 –
EMPLOYMENT 0.19
Employed 33 (84.6%) 10 (66.7%)
Unemployed/retired 5 (12.8%) 4 (26.7%)
Missing 1 1
*p-value ≤0.05.
Table 3. Clinical Variables
Variables
Lifetime
SUD
Absence of
lifetime SUD
p-valuen(%) n(%)
OTHER MEDICAL
COMORBIDITIES 17 (43.6%) 9 (60.0%) 0.28
PSYCHIATRIC
COMORBIDITIES 33 (84.6%) 9 (60.0%) 0.05*
PSYCHOSIS 18 (46.2%) 7 (46.7%) 0.97
PERSONALITY DISORDERS 24 (61.5%) 5 (33.3%) 0.06
DEPRESSIVE DISORDER 5 (12.8%) 3 (20.0%) 0.51
BIPOLAR DISORDER 7 (17.9%) 3 (20.0%) 0.86
ANXIETY 2 (5.1%) 1 (6.7%) 0.82
OBSESSIVE COMPULSIVE
DISORDER 0 (0.0%) 2 (13.3%) <0.05*
COGNITIVE IMPAIRMENT 7 (17.9%) 6 (40.0%) 0.09
COGNITIVE DECAY 1 (2.6%) 0 (0.0%) 0.53
GAMBLING 2 (5.1%) 0 (0.0%) 0.37
EATING DISORDER 1 (2.6%) 0 (0.0%) 0.53
ADHD 0 (0.0%) 0 (0.0%) –
Abbreviation: ADHD, Attention-deficit/hyperactivity disorder.
*p-value ≤0.05.
CNS Spectrums 3
https://doi.org/10.1017/S1092852924000373 Published online by Cambridge University Press
and the second most represented was economic crime (27.6%). The
most prescribed drugs were antipsychotics (85.5%), being 36.9%
FGA and 63.1% SGA. More than 20% of the total sample was
receiving antipsychotics via LAI formulation.
Fifty-four patients had clear notation regarding the presence of
a lifetime SUD. We found statistically significant differences
between patients with lifetime SUD versus patients without lifetime
SUD (Tables 2–6and Figure 1) in terms of absence of a partner
(87.2% vs. 77.6%; p< 0.05), psychiatric comorbidities (84.6% vs.
60.0%; p= 0.05), presence of LAI prescription (28.9% vs. 0%;
p< 0.05), 4 or more hospitalizations (64.1% vs. 33.3%; p< 0.05),
charge with economic crimes (40.5% vs. 6,7%; p< 0.05), previous
crimes (43.6% vs. 13.3%; p< 0.05), and previous incarceration
(35.9% vs. 6.7%; p< 0.05) (Figures 2 and 3). We also found, in
the lifetime SUD population, an association with age (p< 0.05) and
hospitalizations number (p< 0.05). Mann–Whitney U test con-
firmed a significant difference on the number of hospitalizations
between patients with lifetime SUD versus patients without lifetime
SUD (28.4 vs. 18.1; p< 0.05). Logistic regression confirmed that
lifetime substance use may be a risk factor for economic crimes
(OR = 9.5; p< 0.05). We did not find statistically significant
differences between patients with current SUD versus patients
without current SUD.
Discussion
In the present report, sociodemographic, clinical, and forensic
variables were examined with particular emphasis on patients with
SUD; thus, we focused on the role that substance use plays in this
population.
Most of our sample was represented by male patients, with a
mean age of 49 years, partnerless, and unemployed. These results
were also found in numerous studies on psychiatric patients with a
crime history trying to predict violent offense,
19
examining arrest
records of 13,816 individuals receiving services from a regional
Department of Mental Health,
20
describing main characteristics of
forensic psychiatric inpatients,
21–23
analyzing hypothetical corre-
lations between violence and psychosis,
11
and between criminality
and bipolar disorder.
24
The only variable in contrast with most of
the current literature was the level of education, which turned out
to be higher in our sample: 40%, in fact, achieved a diploma or
degree versus 9%–13% found in the current literature.
19,21,23
A
plausible explanation could be that our sample was represented
by patients on voluntary treatment on psychiatric service, whereas,
in the other studies, the sample consisted of the entire psychiatric
population on criminal records.
Consistently with previous findings,
25–27
most of our sample
had a psychiatric comorbidity (71.1%). The most represented
disorder in our sample was psychotic disorder, which affected
almost a half of the sample; specifically, the diagnosis mainly found
was schizophrenia, followed by substance induced psychosis. Psy-
chotic disorders are, in fact, the only illnesses still considered as
independent risk factors which would increase, albeit slightly, the
likelihood of committing crimes, regardless of concomitant sub-
stance use.
28–32
Other psychiatric illnesses found in our sample
included bipolar disorder and major depressive disorder; previ-
ously, other studies showed that these diagnoses, in absence of
concomitant psychotic symptoms, did not play a determinant role
in the commission of crimes.
33–35
Considering the nature of psy-
chotic symptoms, impaired decision-making ability and increased
sensitivity to the environment and external events could explain
this correlation.
36–38
Almost 50% of the present sample suffered from a personality
disorder, mostly borderline personality disorder (BPD), followed
by antisocial personality disorder (APD). Both BPD and APD
DSM-5 criteria include among clinical features, “intense anger or
difficulty controlling anger”and “irritability and aggressiveness, as
indicated by repeated physical fights or assaults,”respectively.
39
Table 4. Hospitalizations
Variables
Lifetime
SUD
Absence of lifetime
SUD
p-valuen(%) n(%)
HOSPITALIZATIONS
<0.05*Less than 4 14 (35.9%) 9 (60.0%)
Four or more 25 (64.1%) 6 (40.0%)
*p-value ≤0.05.
Table 5. Prescription-Related Variables
Variables
Lifetime
SUD
Absence of lifetime
SUD
p-valuen(%) n(%)
MOOD STABILIZER 16 (41.0%) 6 (40.0%)
0.94
Missing ––
FGA 10 (25.6%) 8 (53.3%)
0.05*
Missing ––
SGA 26 (66.7%) 6 (40.0%)
0.07
Missing ––
LAI PRESCRIPTION 11 (28.2%) 0 (0.0%)
0.02*
Missing 2 2
Abbreviations: FGA, first-generation antipsychotics; LAI, long-acting injection; SGA, second-
generation antipsychotics.
*p-value ≤0.05.
Table 6. Forensic Variables
Variables
Lifetime
SUD
No lifetime
SUD
p-valuen(%) n(%)
ECONOMIC CRIME 15 (38.5%) 1 (6.7%)
0.02*
Missing 2 –
VIOLENCE AGAINST OTHERS 24 (61.5%) 13 (86.7%)
0.12
Missing 2 –
PREVIOUS CRIMES 17 (43.6%) 2 (13.3%)
0.02*
Missing 4 –
PREVIOUS INCARCERATION 14 (35.9%) 1 (6.7%)
0.02*
Missing 3 –
PREVIOUS SECURITY
PSYCHIATRIC MEASURE
(REMS)
3 (7.7%) 0 (0.0%)
0.25
Missing 3 –
Note: For binary variables, p-values were calculated by chi-square test.
Abbreviation: REMS, residenza per l’esecuzione delle misure di sicurezza.
*p-value ≤0.05.
4 F. Achilli et al.
https://doi.org/10.1017/S1092852924000373 Published online by Cambridge University Press
Those features have also been highlighted by the current literature;
some authors focused on the differences between outpatients and
the incarcerated ones,
40
some on the impact of SUD and person-
ality disorders on criminal behavior,
41,42
while others studied
lifetime risk and correlates of incarceration excluding substance-
related mental illness.
43
These findings emerge also in larger
descriptive literature.
44
The absence of a partner was prevalent in the population with
lifetime substance use compared to the population of nonusers
(p< 0.05). Some authors have studied the role of rejection sensi-
tivity and risk behavior, finding higher rates in patients with a
history of substance abuse.
45
Risk behavior and higher rejection
sensitivity could be related to greater difficulty in establishing stable
relationships.
Borderline statistical significance was found regarding the prev-
alence of psychiatric comorbidities (p= 0.05) in the lifetime sub-
stance users group compared to the nonusers group: this is partly
intrinsically related to the definition of the sample, consisting in
patients who have experienced several stressful events and have
multiple risk factors for psychiatric diseases.
46
The present study, moreover, highlighted the use of LAI therapy
exclusively in the substance user population, compared to nonusers
Figure 1. Significant differences between patients with Lifetime SUD vs Absence of Lifetime SUD.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Forensic Variables
Figure 2. Forensic variables regarding the whole sample.
CNS Spectrums 5
https://doi.org/10.1017/S1092852924000373 Published online by Cambridge University Press
(p< 0.05). The reason may lie in several causes: first of all, these are
complex, comorbid, chronic patients who need multispecialty
treatment; injectable therapies are likely to be better tolerated by
the patient; moreover, recent studies have shown that the earlier an
LAI is prescribed, the more quickly the patient is stabilized, reduc-
ing the risk of relapse.
47–49
Substance users also showed a higher frequency of hospitaliza-
tion compared to nonusers (more than 3 times; p< 0.05). This
finding is supported by the present literature, which also identifies
past hospitalizations as a risk factor for recurrence.
50–53
Recidivism
of dysfunctional or criminal behavior has been related to a difficulty
of institutions to best support these individuals.
53
Consistently with several other studies,
27,41,54
substance users
more frequently committed economic crimes (p< 0.05) probably
related to the need to obtain the drug of abuse. This also generates a
vicious cycle driven by craving: users spend all the money they have
to obtain the substance and are willing to commit crimes against
property in order to afford more of it, in ever-increasing quantities,
as their tolerance requires.
In contrast to other studies,
52,54,55
we did not find a prevalence
of drug dealing crimes in substance users. The possible interpreta-
tion could be that as stated above, our sample included people
voluntarily attending an outpatient facility, while drug dealing is a
crime often related to a refusal of institutional health care.
56,57
As already stated by other authors,
27,52,53,55,58–60
previous
offenses and previous incarceration were found to be signifi-
cantly higher (p< 0.05) in the substance users’population. This
finding affects the risk of recidivism of psychiatric patients with
SUD.
54
In this study emerges that psychiatric patients with a history of
crimes and lifetime SUD need a comprehensive consideration, they
could benefit from an approach that further integrates biological,
psychological, and social factors; those elements should be seen not
only as complementary but as “facets of the same dynamical
system.”
61
A novel precision approach and the adoption of indi-
vidualized treatments could break the vicious cycle that leads to
recidivism.
62
The abovementioned results should be interpreted considering
some methodological limitations. First, the cross-sectional nature
of the study allowed only a 1-time assessment. Second, variables
were obtained retrospectively, being susceptible to recall bias. This
was a monocentric study; thus, it may lack external validity. More-
over, the absence of variables such as severity of addiction, absti-
nence duration, and the relationship between the substance
consumed and psychopathological variables could have affected
the considerations drawn from the results obtained. Due to the
nature of this study, we were not able to retrace some variables like
antidepressant prescriptions and the personality disorder cluster
diagnosed. Diagnoses have not been explored in dept through
psychometric scales, leaving out some patients’specifics. Finally,
sample size should be increased.
Conclusion
The results of the present research highlight that individuals with a
history of crime records and lifetime SUD tend to have higher rates
of hospitalization, a higher amount of criminal reoffending, and an
increased number of incarcerations, particularly for economic
crimes.
The complexity of those patients lies not only in medical and
psychiatric reasons but also represents a social and economic
challenge for the whole community. As future perspectives, a bigger
sample could be examined, possibly involving other community
mental health centers; it could be helpful to evaluate variations in
time and in terms of age ranges, adopting a longitudinal approach.
Author contribution. Conceptualization: B.M.D., B.B., D.G., E.P., F.A.; Writ-
ing –review & editing: B.M.D., B.B.; Data curation: A.F., D.G., E.P., L.M., M.C.,
M.L., F.A.; Formal analysis: B.B., F.A.; Writing –original draft: E.L., M.C., M.L.,
S.L., F.A.; Investigation: S.L., F.A.
Financial support. This research did not receive any specific grant from
funding agencies in the public, commercial, or not-for profit sectors.
Figure 3. Percentage of psychiatric comorbidities regarding the whole sample.
6 F. Achilli et al.
https://doi.org/10.1017/S1092852924000373 Published online by Cambridge University Press
Disclosure. B.M.D.O. has received lecture honoraria from Angelini, Janssen,
Lundbeck, Livanova, Arcapharma, and Neuraxpharm. The other co-authors do
not have any disclosures.
References
1. Fazel S, Danesh J. Serious mental disorder in 23 000 prisoners: a systematic
review of 62 surveys. Lancet. 2002;359(9306):545–550. doi:10.1016/S0140-
6736(02)07740-1.
2. Forrester A, Hopkin G. Mental health in the criminal justice system: a
pathways approach to service and research design. Criminal Behaviour and
Mental Health. 2019;29(4):207–217. doi:10.1002/cbm.2128.
3. Peloso PF, D’Alema M, Fioritti A. Mental health care in prisons and the
issue of forensic hospitals in Italy. Journal of Nervous & Mental Disease.
2014;202(6):473–478. doi:10.1097/NMD.0000000000000147.
4. Rossetto I, Clerici M, Franconi F, et al. Differences between readmitted and
non-readmitted women in an Italian forensic unit: a retrospective study.
Frontiers in Psychology. 2021;12:708873. doi:10.3389/fpsyg.2021.708873.
5. Italian Legislation. Legge 17 febbraio 2012, n.9 (2012).
6. Italian Legislation. Legge 30 maggio 2014, n.81 (2014).
7. Völlm BA, Clarke M, Herrando VT, et al. European Psychiatric Association
(EPA) guidance on forensic psychiatry: evidence based assessment and
treatment of mentally disordered offenders. European Psychiatry. 2018;51:
58–73. doi:10.1016/j.eurpsy.2017.12.007.
8. Sampson S, Edworthy R, Völlm B, et al. Long-term forensic mental health
services: an exploratory comparison of 18 European countries. Interna-
tional Journal of Forensic Mental Health. 2016;15(4):333–351. doi:10.1080/
14999013.2016.1221484.
9. Fazel S, Gulati G, Linsell L, et al. Schizophrenia and violence: systematic
review and meta-analysis. PLOS Medicine. 2009;6(8):e1000120. doi:
10.1371/journal.pmed.1000120.
10. Ogloff JRP, Talevski D, Lemphers A, et al. Co-occurring mental illness,
substance use disorders, and antisocial personality disorder among clients
of forensic mental health services. Psychiatric Rehabilitation Journal. 2015;
38(1):16–23. doi:10.1037/prj0000088.
11. Witt K, van Dorn R, Fazel S. Risk factors for violence in psychosis:
systematic review and meta-regression analysis of 110 studies. PLoS One.
2013;8(2):e55942. doi:10.1371/journal.pone.0055942.
12. Drake RE, McHugo GJ, Xie H, et al. Ten-year recovery outcomes for
clients with co-occurring schizophrenia and substance use disorders.
Schizophrenia Bulletin.2005;32(3):464–473. doi:10.1093/schbul/sbj064.
13. Probst T, Bezzel A, Hochstadt M, et al. Criminal recidivism after forensic
psychiatric treatment. A multicenter study on the role of pretreatment,
treatment-related, and follow-up variables. Journal of Forensic Sciences.
2020;65(4):1221–1224. doi:10.1111/1556-4029.14281.
14. Biancosino B, Delmonte S, Grassi L, et al. Violent behavior in acute
psychiatric inpatient facilities. Journal of Nervous & Mental Disease.
2009;197(10):772–782. doi:10.1097/NMD.0b013e3181bb0d6b.
15. Amore M, Menchetti M, Tonti C, et al. Predictors of violent behavior
among acute psychiatric patients: clinical study. Psychiatry and Clinical
Neurosciences. 2008;62(3):247–255. doi:10.1111/j.1440-1819.2008.01790.x.
16. Lombardi V, Veltri A, Montanelli C, et al. Sociodemographic, clinical and
criminological characteristics of a sample of Italian Volterra REMS
patients. International Journal of Law and Psychiatry. 2019;62:50–55. doi:
10.1016/j.ijlp.2018.09.009.
17. Archibald L. Alcohol use disorder and schizophrenia and schizoaffective
disorders. Alcohol Research. 2019;40(1):arcr.v40.1.06. doi:10.35946/arcr.
v40.1.06.
18. Karoly HC, YorkWilliams SL, Hutchison KE. Clinical neuroscience of
addiction: similarities and differences between alcohol and other drugs.
Alcoholism: Clinical and Experimental Research. 2015;39(11):2073–2084.
doi:10.1111/acer.12884.
19. Fazel S, Wolf A , Larsson H, et al. Identifi cation of low risk of viole nt crime
in severe mental illness with a clinical prediction tool (Oxford Mental
Illness and Violence tool [OxMIV]): a derivation and validation study.
Lancet Psychiatry. 2017;4(6):461–468. doi:10.1016/S2215-0366(17)
30109-8.
20. Fisher WH, Roy-Bujnowski KM, Grudzinskas AJ, et al. Patterns and preva-
lence of arrest in a statewide cohort of mental health care consumers.
Psychiatric Services. 2006;57(11):1623–1628. doi:10.1176/ps.2006.57.11.1623.
21. Gu Y, Guo H, Zhou J, et al. Socio-demographic, clinical and offense-related
characteristics of forensic psychiatric inpatients in Hunan, China: a cross-
sectional survey. BMC Psychiatry. 2023;23(1):48. doi:10.1186/s12888-022-
04508-8.
22. Lin C-H, Hsieh W-C, Liu H-W, et al. Psychiatric evaluations in offenders
with mental illness: a case series. Taiwanese Journal of Psychiatry. 2022;36
(1):39. doi:10.4103/TPSY.TPSY_5_22.
23. Streb J, Lutz M, Dudeck M, et al. Are women really different? Comparison
of men and women in a sample of forensic psychiatric inpatients. Front
Psychiatry. 2022;13:857468. doi:10.3389/fpsyt.2022.857468.
24. Webb RT, Lichtenstein P, Larsson H, et al. Suicide, hospital-presenting
suicide attempts, and criminality in bipolar disorder. Journal of Clinical
Psychiatry. 2014;75(08):e809–e816. doi:10.4088/JCP.13m08899.
25. Elbogen EB, Johnson SC. The intricate link between violence and mental
disorder. Archives of General Psychiatry. 2009;66(2):152. doi:10.1001/arch-
genpsychiatry.2008.537.
26. Palijan TZ, MuzinićL, Radeljak S. Psychiatric comorbidity in forensic
psychiatry. Psychiatria Danubina. 2009;21(3):429–436.
27. Pagerols M, Valero S, Dueñas L, et al. Psychiatric disorders and comorbid-
ity in a Spanish sample of prisoners at the end of their sentence: prevalence
rates and associations with criminal history. Frontiers in Psychology. 2023;
13:1039099. doi:10.3389/fpsyg.2022.1039099.
28. McCabe PJ, Christopher PP, Druhn N, et al. Arrest types and co-occurring
disorders in persons with schizophrenia or related psychoses. Journal of
Behavioral Health Services & Research. 2012;39(3):271–284. doi:10.1007/
s11414-011-9269-4.
29. Fisher WH, Simon L, Roy-Bujnowski K, et al. Risk of arrest among public
mental health services recipients and the general public. Psychiatric Ser-
vices. 2011;62(1):67–72. doi:10.1176/ps.62.1.pss6201_0067.
30. Hawthorne WB, Folsom DP, Sommerfeld DH, et al. Incarceration among
adults who are in the public mental health system: rates, risk factors, and
short-term outcomes. Psychiatric Services. 2012;63(1):26–32. doi:10.1176/
appi.ps.201000505.
31. McCabe PJ, Christopher PP, Pinals DA, et al. Predictors of criminal justice
involvement in severe mania. Journal of Affective Disorders. 2013;149(1–3):
367–374. doi:10.1016/j.jad.2013.02.015.
32. Falconer E, El-Hay T, Alevras D, et al. Integrated multisystem analysis in a
mental health and criminal justice ecosystem. Health Justice. 2017;5(1):4.
doi:10.1186/s40352-017-0049-y.
33. García OP. Trastornos mentales y violencia: Implicaciones jurídico
forenses. https://dialnet.unirioja.es/servlet/articulo?codigo=7064109.
34. Fossa G ZEVA. Il malato di mente autore di reato nelle strutture residen-
ziali: una ricerca in una comunità terapeutica The forensic patient in
psychiatric residential facilities: a research in a Therapeutic Community.
https://ojs.pensamultimedia.it/index.php/ric/article/view/524.
35. López M, Laviana M, Saavedra FJ, et al. Problemas de salud mental en
población penitenciaria. Un enfoque de salud pública. Revista de la Asocia-
ción Española de Neuropsiquiatría. 2021;41(140):87–111. doi:10.4321/
S0211-57352021000200005.
36. Leclerc MP, Regenbogen C, Hamilton RH, et al. Some neuroanatomical
insights to impulsive aggression in schizophrenia. Schizophrenia Research.
2018;201:27–34. doi:10.1016/j.schres.2018.06.016.
37. Yee NYL, Large MM, Kemp RI, et al. Severe non-lethal violence during
psychotic illness. Australian & New Zealand Journal of Psychiatry. 2011;45
(6):466–472. doi:10.3109/00048674.2011.541417.
38. Yee N, Matheson S, Korobanova D, et al. A meta-analysis of the relation-
ship between psychosis and any type of criminal offending, in both men and
women. Schizophrenia Research. 2020;220:16–24. doi:10.1016/j.
schres.2020.04.009.
39. American Psychiatric Association. Diagnostic and Statistical Manual of
Mental Disorders. Arlington: American Psychiatric Association Publishing;
2022. doi:10.1176/appi.books.9780890425787.
CNS Spectrums 7
https://doi.org/10.1017/S1092852924000373 Published online by Cambridge University Press
40. Esposito CM, Ceresa A, Auxilia AM, et al. Which clinical and demographic
factors are related to incarceration in male patients with antisocial person-
ality disorder? International Journal of Offender Therapy and Comparative
Criminology. 2023;67:1630–1641. doi:10.1177/0306624X221139073.
41. Flórez G FVGLCMPMSPA. Personality disorders, addictions and psychop-
athy as predictors of criminal behaviour in a prison sample. Revista
Española de Sanidad Penitenciaria 2019;21:62–79.
42. Howard R, Hasin D, Stohl M. Substance use disorders and criminal justice
contact among those with co-occurring antisocial and borderline person-
ality disorders: findings from a nationally representative sample. Personal
Mental Health. 2021;15(1):40–48. doi:10.1002/pmh.1491.
43. Nakic M, Stefanovics EA, Rhee TG, et al. Lifetime risk and correlates of
incarceration in a nationally representative sample of U.S. adults with non-
substance-related mental illness. Social Psychiatry and Psychiatric Epide-
miology. 2022;57(9):1839–1847. doi:10.1007/s00127-021-02158-x.
44. Völlm BA, Edworthy R, Huband N, et al. Characteristics and pathways of
long-stay patients in high and medium secure settings in England; a
secondary publication from a large mixed-methods study. Front Psychiatry.
2018;9:140. doi:10.3389/fpsyt.2018.00140.
45. Woerner J, Kopetz C, Lechner WV, et al. History of abuse and risky sex
among substance users: the role of rejection sensitivity andthe need to belong.
Addictive Behaviors.2016;62:73–78. doi:10.1016/j.addbeh.2016.06.006.
46. Zijlmans J, van Duin L, Jorink M, et al. Disentangling multiproblem
behavior in male young adults: a cluster analysis. Development and Psy-
chopathology. 2021;33(1):149–159. doi:10.1017/S0954579419001652.
47. Hsu H-F, Kao C-C, Lu T, et al. Differences in the effectiveness of long-
acting injection and orally administered antipsychotics in reducing rehos-
pitalization among patients with schizophrenia receiving home care ser-
vices. Journal of Clinical Medicine 2019;8(6):823. doi:10.3390/jcm8060823.
48. Koola MM, Wehring HJ, Kelly DL. The potential role of long-acting
injectable antipsychotics in people with schizophrenia and comorbid sub-
stance use. Journal of Dual Diagnosis. 2012;8(1):50–61. doi:10.1080/
15504263.2012.647345.
49. Marcus SC, Zummo J, Pettit AR, et al. Antipsychotic adherence and
rehospitalization in schizophrenia patients receiving oral versus long-act-
ing injectable antipsychotics following hospital discharge. Journal of Man-
aged Care & Specialty Pharmacy. 2015;21(9):754–769. doi:10.18553/
jmcp.2015.21.9.754.
50. Olivares JM, Sermon J, Hemels M, et al. Definitions and drivers of relapse in
patients with schizophrenia: a systematic literature review. Annals of Gen-
eral Psychiatry. 2013;12(1):32. doi:10.1186/1744-859X-12-32.
51. Quanbeck CD, Stone DC, McDermott BE, et al. Relationship between
criminal arrest and community treatment history among patients with
bipolar disorder. Psychiatric Services. 2005;56(7):847–852. doi:10.1176/
appi.ps.56.7.847.
52. Mundt AP, Baranyi G. The unhappy mental health triad: comorbid severe
mental illnesses, personality disorders, and substance use disorders in
prison populations. Front Psychiatry. 2020;11:804. doi:10.3389/
fpsyt.2020.00804.
53. Karlsson A, Håkansson A. Crime-specific recidivism in criminal justice
clients with substance use—a cohort study. International Journal of Envi-
ronmental Research and Public Health. 2022;19(13):7623. doi:10.3390/
ijerph19137623.
54. Zgoba KM, Reeves R, Tamburello A, et al. Criminal recidivism in inmates
with mental illness and substance use disorders. Journal of the American
Academy of Psychiatry and the Law. 2020;48(2):209–215. doi:10.29158/
JAAPL.003913-20.
55. James DJ, Glaze LE. Mental Health Problems of Prison. http://bjs.ojp/usdoj.
gov/content/pub/pdf/mhppji.pdf.
56. Hepburn K, Barker B, Nguyen P, et al. Initiation of drug dealing among a
prospective cohort of street-involved youth. American Journal of Drug and
Alcohol Abuse. 2016;42(5):507–512. doi:10.1080/00952990.2016.1186684.
57. Small W, Maher L, Lawlor J, et al. Injection drug users’involvement in drug
dealing in the downtown eastside of Vancouver: social organization and
systemic violence. International Journal of Drug Policy. 2013;24(5):479–
487. doi:10.1016/j.drugpo.2013.03.006.
58. Baillargeon J, Penn JV, Knight K, et al. Risk of reincarceration among
prisoners with co-occurring severe mental illness and substance use disor-
ders. Administration and Policy in Mental Health and Mental Health
Services Research. 2010;37(4):367–374. doi:10.1007/s10488-009-0252-9.
59. Whiting D, Lichtenstein P, Fazel S. Violence and mental disorders: a
structured review of associations by individual diagnoses, risk factors,
and risk assessment. Lancet Psychiatry. 2021;8(2):150–161. doi:10.1016/
S2215-0366(20)30262-5.
60. Smith NTL. Comorbid Substance and Non-Substance Mental Health Dis-
orders and Re-Offending Among NSW Prisoners; 2010.
61. Gómez-Carrillo A, Paquin V, Dumas G, et al. Restoring the missing person
to personalized medicine and precision psychiatry. Frontiers in Neurosci-
ence 2023;17:1041433. doi:10.3389/fnins.2023.1041433.
62. Wilkinson CS, Luján MÁ, Hales C, et al. Listening to the data: computa-
tional approaches to addiction and learning. Journal of Neuroscience. 2023;
43(45):7547–7553. doi:10.1523/JNEUROSCI.1415-23.2023.
8 F. Achilli et al.
https://doi.org/10.1017/S1092852924000373 Published online by Cambridge University Press
