Outline. The role of mental illness in recidivism. ReconvicJon rates are high 11/12/2017

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1 Outline The role of mental illness in recidivism Seena Fazel, Department of Psychiatry, University of Oxford Background recidivism and role of mental illness New study ImplicaJons Risk assessment ReconvicJon rates are high Re- offending rates not decreased over Jme in E&W Fazel & Wolf, PLoS One 2015 Ministry of JusJce, StaJsJcs bullejn

2 11/12/2017 Are psychojc disorders associated with recidivism? Previous reviews downplay clinical factors Fazel, Scz Bull 2012 New study Swedish populajon High quality najonal registers that can be linked accurately Similar rates of violent reoffending, mental illness and substance abuse in prisoners; lower rates of incarcerajon Methods Population and data sources SWEDISH REGISTERS INCLUSION CRITERIA Total Population Patient Cause of Death All prison releases between 2000 and 2009 FOLLOW UP Violent crime at 1,2 and 5 years Age National Crime Longitudinal Integration Database 2

3 QuesJons Is there an associajon between mental disorders and violent reoffending? To what extent is this associajon confounded? And by what? Are there differences by individual diagnoses? Sample descripjve stajsjcs Male Female Number of individuals Any psychiatric disorder (%) Alcohol abuse (%) Drug abuse (%) Personality disorder (%) ADHD (%) Other developmental or childhood disorder (%) Schizophrenia spectrum disorder (%) Bipolar disorder (%) Depression (%) Anxiety disorder (%) Higher rates of violent recidivism Probability of violent reoffending by Jme aaer release Kaplan-Meier survival estimates Year after release Male prisoner without psychiatric disorder Male prisoner with psychiatric disorder Female prisoner without psychiatric disorder Female prisoner with psychiatric disorder 3

4 Non- specific links? 4

5 Findings are generalizable to other countries ImplicaJons NaJonal violence prevenjon strategies should include prison health Very lidle familial confounding suggesjng causality Non- specificity by diagnosis suggests shared mechanisms (emojonal dysregulajon?) MulJmorbidity important Overall implicajons ExplanaJons of reoffending criminological, psychological, medical/public health What next for risk assessment? What next for risk management? New Scien1st,

6 11/12/2017 Coid, JFFP 2011 And what does high risk mean? Singh, BJP

7 Problems Costly (direct and indirect) Time consuming Not transparent PublicaJon bias Evidence base is variable Guru- like system of training Meaningless cut- offs? Don t improve outcomes So lets do it differently and properly What precedents are there? 7

8 So lets do it differently and properly What precedents are there? Develop web based calculator, free to use, requires no training Methods Population and data sources SWEDISH REGISTERS INCLUSION CRITERIA Total Population Patient Cause of Death National Crime Longitudinal Integration Database All prison releases between 2000 and 2009 Age FOLLOW UP Violent crime within 12/24 months Any crime within 12/24 months Methods Samples & Analyses Methods Risk factors and event SOCIO-DEMOGRAPHIC SAMPLES prisoners Derivation sample (n= ) Validation sample (n= ) DERIVATION Cox regression Risk factor groups Low / Medium / High 10% 50% All pre-specified VALIDATION Sensitivity/ Specificity PPV/NPV AUC Brier score Sex, age, immigrant status, marital status, educational level, income, deprivation CRIMINOGENIC Index violent crime, previous violent crime, length of incarceration VIOLENT CRIME Homicide, assault, robbery, arson, sexual offense, illegal threat or intimidation within 24 months 18 % CLINICAL Alcohol or drug disorders, mental illness, developmental or childhood disorders 8

9 Results Included risk factors Results Risk factor odds ratios MALE 93 % EMPLOYMENT 25 % Variable Adjusted Odds Ratio Variable Adjusted Odds Ratio MEAN AGE IMMIGRANT STATUS LENGTH OF INCARCERATION VIOLENT INDEX OFFENCE PREVIOUS VIOLENT CRIME UNMARRIED EDUCATION 36 yrs 31 % 38 % 53 % 65 % DISPOSABLE INCOME NEIGHBOURHOOD DEPRIVATION ALCOHOL USE DISORDER DRUG USE DISORDER ANY MENTAL DISORDER ANY SEVERE MENTAL DISORDER 22 % 23 % 22 % 3 % DEVELOPMENTAL/CHILDHOOD DIS 3 % Sex (female) 0.51 ( ) Age (per 5 years) 0.84 ( ) Immigrant status 0.97 ( ) Length of incarceration 6-11 months months 24+ months Violent index offence Previous violent crime 0.85 ( ) 0.69 ( ) 0.55 ( ) 1.53 ( ) 2.41 ( ) Unmarried 1.08 ( ) Education level 9-11 years 12+ years 0.83 ( ) 0.65 ( ) Employment 0.68 ( ) Disposable income Zero Low (<20º) Medium (20º - 80º) High (>80º) Neighbourhood deprivation Alcohol use disorder 1.69 ( ) 1.68 ( ) 1.45 ( ) 1.57 ( ) 1.03 ( ) 1.41 ( ) Drug use disorder 1.51 ( ) Any mental disorder 1.09 ( ) Any severe mental disorder 1.10 ( ) Results Validation and web tool 67 % 70 % Sensitivity Specificity % 99 % c-index (AUC) PPV NPV 9

10 SENSITIVITY SPECIFICITY OXREC OXFORD RISK OF RECIDIVISM TOOL 67% 70% POSITIVE PREDICTIVE VALUE 37% NEGATIVE PREDICTIVE VALUE AREA UNDER THE CURVE Results Comparison with other tools 99% VIOLENCE TOOLS Mean values for HCR-20, SARA, SAVRY, and VRAG* SENSITIVITY SPECIFICITY 36% 92% POSITIVE PREDICTIVE VALUE 41% NEGATIVE PREDICTIVE VALUE AREA UNDER THE CURVE 91% Conclusions Scalable tool Overall similar predicjve abilijes to current approaches More effecjve targejng than current tools sensijvity 67% IdenJfies those with drug and alcohol needs, and mental health problems Simple way of providing BASELINE risk Needs to be complemented with more individualised needs assessments *Fazel et al., BMJ 2012 Results Published paper Prediction of violent reoffending on release from prison: derivation and external validation of a scalable tool Seena Fazel, Zheng Chang, Thomas Fanshawe, Niklas Långström, Paul Lichtenstein, Henrik Larsson, Susan Mallett Summary Background More than 30 million people are released from prison worldwide every year, who include a group at high risk of perpetrating interpersonal violence. Because there is considerable inconsistency and inefficiency in identifying those who would benefit from interventions to reduce this risk, we developed and validated a clinical prediction rule to determine the risk of violent offending in released prisoners. Methods We did a cohort study of a population of released prisoners in Sweden. Through linkage of population-based registers, we developed predictive models for violent reoffending for the cohort. First, we developed a derivation model to determine the strength of prespecified, routinely obtained criminal history, sociodemographic, and clinical risk factors using multivariable Cox proportional hazard regression, and then tested them in an external validation. We measured discrimination and calibration for prediction of our primary outcome of violent reoffending at 1 and 2 years using cutoffs of 10% for 1-year risk and 20% for 2-year risk. Findings We identified a cohort of prisoners released in Sweden between 2001 and 2009, with incidents of violent reoffending during this period. We developed a 14-item derivation model to predict violent reoffending and tested it in an external validation (assigning individuals to the derivation sample and to the validation sample). The Lancet Psychiatry 2016; 3: Published Online April 13, S (16) See Comment page 493 Department of Psychiatry, Warneford Hospital (Prof S Fazel MD, Z Chang PhD) and Department of Primary Care Health Sciences (T Fanshawe PhD), University of Oxford, Oxford, UK; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden Summary High rates of recidivism Previous reviews of role of mental illness misleading New research using large sample, novel design, reliable exposures and hard outcomes All mental disorders associated with violent recidivism NaJonal violence strategies, prison health services, and risk assessment need review in light of this 10

11 References (open access) Fazel S, Chang Z, Fanshawe T, Långström N, Lichtenstein P, Larsson H, Malled S. PredicJon of violent reoffending on release from prison: derivajon and external validajon of a scalable tool. Lancet Psychiatry 2016; 3: PMID: Chang Z, Larsson H, Lichtenstein P, Fazel S. Psychiatric disorders and violent reoffending: a najonal cohort study of convicted prisoners in Sweden. Lancet Psychiatry 2015; 2: PMID: Achim Wolf Psychiatry, Oxford Acknowledgements Zheng Chang Henrik Larsson Johan Zetterqvist Karolinska Institutet Karolinska Institutet Karolinska Institutet OxRec: Niklas Långström Karolinska Institutet Paul Lichtenstein Karolinska Institutet Susan Mallett University of Birmingham Thomas Fanshawe Primary Care, Oxford seena.fazel@psych.ox.ac.uk 11