Prof Janet Treasure FRCPsych, Angélica M Claudino PhD, Nancy Zucker PhD

Summary

This Seminar adds to the previous Lancet Seminar about eating disorders, published in 2003, with an emphasis on the biological contributions to illness onset and maintenance. The diagnostic criteria are in the process of review, and the probable four new categories are: anorexia nervosa, bulimia nervosa, binge eating disorder, and eating disorder not otherwise specified. These categories will also be broader than they were previously, which will affect the population prevalence; the present lifetime prevalence of all eating disorders is about 5%. Eating disorders can be associated with profound and protracted physical and psychosocial morbidity. The causal factors underpinning eating disorders have been clarified by understanding about the central control of appetite. Cultural, social, and interpersonal elements can trigger onset, and changes in neural networks can sustain the illness. Overall, apart from studies reporting pharmacological treatments for binge eating disorder, advances in treatment for adults have been scarce, other than interest in new forms of treatment delivery.

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Introduction

Forensic psychiatry represents the specific area of identification, discussion and guidance regarding issues that encompass the interconnection between both the legal and medical worlds. (1) It is a subspecialty of general psychiatry which obtained full recognition as a specialty in its own right in the 1970s. (2, 3, 4) It aimed at addressing the pragmatic problems that involved dealing with individuals who committed offences. (5)

This paper aims at reviewing the historical landmarks about the evolution of forensic psychiatry, its practice in various countries and finally its impact on the future of mental health.

History: The Sefeloge Case

The history of forensic psychiatry appears to have been significantly influenced by the framework of two professions, medicine and law. With the increasing power of the legal and medical professions, people gradually developed a quest for greater public esteem in society. (6) One of the major landmarks in the development of forensic psychiatry is the assassination attempt of a mentally ill Sergeant named Maximillian Joseph Sefeloge on the Prussian King Friedrich Wilhelm IV in the 1850s. (7) The case of Sefeloge was one of the first whereby medico-historical examination was sought because the motive of the act was unclear to the authorities. A forensic scientist and three well-known psychiatrists were summoned to carry out this forensic examination. These forensic experts proved to be particularly competent because of their common experience in dealing with psychiatric patients. This radically unique case from nineteenth century Germany showed that the statement of a psychiatrist could be accepted in courts as an expert witness in order to evaluate crimes pertaining to unclear mental conditions and from there the evolution of this specialty could proceed without hindrance. (6,7)

Forensic Psychiatry in Different Countries

During the past few years, forensic psychiatry as a subspecialty has been recognized and accepted in many countries namely US, UK, Canada, Israel, Australia, Sweden, Netherlands and New Zealand. (9, 10) However, forensic psychiatry is yet to be recognized in many countries of Africa and Asia, where there is an acute shortage of human resource. (11) Moreover, most professionals who are involved in the field of forensic psychiatry has not received the proper training before practicing in this area. Besides, it is to be noted that only a limited amount of information is available on the status of forensic psychiatry in African nations which makes it considerably difficult to establish a uniform judgment. (12) Most states in Africa have roughly one psychiatrist per one million inhabitants and in South Africa the number of psychiatrists has remained virtually stagnant for the last 30 years. (13)

Forensic Psychiatry appears to be different from one country to another due to different historical, developmental, legal and mental health systems. (14) However, there are some commonalities shared across countries; the need to ensure the treatment of seriously mentally ill patients who become delinquent and the opportunity use forensic psychiatry as evidence in court. Forensic psychiatrists in different countries work to prevent relapse of mentally disordered offenders. It has developed special knowledge and skills that pertain especially to violence and sexual deviance. (9)

Forensic Psychiatry in Sweden

In Sweden, the number of mentally disordered patients is increasing steadily. According to recent studies, a disproportionally large number of former psychiatric inpatients appear in the judicial system because of criminal charges (15,16,17). Further evidence showing that there is a nexus between violence, crime and mental illness has been presented during the last decade. Out of the 15,000 individuals who are convicted of a crime each year in Sweden, 3.5% undergo a forensic psychiatric examination. (18) Individuals in this particular group may require treatment and support services to a significantly larger extent compared to the general population. (10)

Forensic Psychiatry in Netherlands

Forensic Psychiatry is considered very important in Netherlands, with many patients treated in special forensic mental health institutes. Treatment is provided to offenders who at the time of the crime had a psychiatric disturbance such as psychosis and addiction before they are released. (19) These offenders are treated in psychiatric hospitals that are removed from the community. Patients are put into jails, but within the institution there is a psychiatric, not a prison’s culture. (19)

Art therapies are often an integrated part of multidisciplinary treatment in most psychiatric institutions. (20, 21) About 10% of art therapists work in forensic institutions. In forensic psychiatry, art therapists from a range of different professions including drama, music, art and dance-movement collaborate in teams to participate in the overall treatment plan. (22, 23, 24) Treatment in a forensic institution consists of an integrated program involve several professionals namely psychiatrists, psychologists and art therapists.

In the last decade, the art therapies tried to affect the personality of these patients by modifying the way the patient feels, thinks, acts in concrete situations. The therapies become more “re-educative”, which means that the patient is trained to change specific cognitions, feelings and behaviors related to one problem area. This makes art therapies valuable components in the treatment of forensic patients. An important core reason for the use of art therapies in forensic psychiatry is their orientation to action. The experiential and active nature of the art therapies enable regulation of tension, impulse control, regulation of aggression planning and structuring of behavior and the development of interactive competencies. (19)

A reduction of 29% in disciplinary measures in a prison as a result of 13 months of art therapies noted in 1998 and the amount of transgressions requiring disciplinary measures as a result of art therapy decreased by 75–81%. (25,26) Two years after patients were dismissed, 69% of the persons who took part in art therapy did not re-offend compared to the control group without art therapy, in which 42% did not re-offend. (27)

Forensic Psychiatry in Singapore

Singapore is a multiethnic, modern country equipped with state of the art mental health care facilities. It has a large number of mental health professionals for the population as compared to most Asian countries and its crime rate is significantly low in comparison to most Western countries. In Singapore, studies reveal that the number of foreigners who committed homicide was significantly higher compared to the proportion of permanent residents. (29) These foreigners who committed homicide seem to suffer from serious mental illness like mood and psychotic disorders. Hence, psychiatrists recommend strongly that newly appointed employees be offered courses on psychiatric services and work stress reduction programs. (28)

Forensic Psychiatry in New Zealand

New Zealand consists of only 3 million inhabitants and the native New Zealanders are the Maori. Research shows that in New Zealand mentally ill offenders of serious crimes are securely detained for long periods, 6 years for those charged with murder. (30) Even if most patients were re-admitted to the hospital, only 6% had violently re-offended within 2 years of release from prisons. The authors found that re-offending seemed to take place soon after discharge and the Maori ethnicity was associated with violent re-conviction. The New Zealand forensic psychiatric service offers a full package of assertive community treatment programs, reinforced by cultural engagement, integration into the community and familial engagement. (31) Furthermore, in New Zealand innovative, culturally sensitive rehabilitation schemes are helping the Maori patients and these can be used as models for other countries. (28)

Forensic Psychiatry in Australia

A study carried out by Brett and Blumberg described the use of video-conferencing in facilitating the provision of specialized forensic services to courts in remote areas of Australia. (32) The effective use of video-conferencing in forensic psychiatric work allows large sums of money to be saved. Teleconferencing facility costs (Aus) $ 50 per hour compared to the extensive cost of flying patients or transporting them by road using custodial services. Besides, access to care in Australia has been appropriately handled with telemedicine and telepsychiatry. (33)

Forensic Psychiatry in Japan

An article published by Weisstub and Carvey revealed that the new forensic mental health laws adopted in 2003 and put into practice in 2005 addressed a lot of issues concerning reforms in the mental health sector. (34) These included issues concerning the refusal of medical treatment, supervision of mentally ill people who are prone to cause harm and the need to cement the relationships between forensic reforms and other related systems. The new law has been grafted to the existing laws on involuntary commitment, long term care for the aged, substituted decision making and a better system of care for serious offenders. Furthermore, the authors of the study urged a form of diversionary system so that mentally disordered persons who commit minor crimes can be appropriately referred thus avoiding ongoing stigmatization and prolonged institutionalization. (28)

Future

As the availability of beds in mental hospitals is dwindling, the number of people in prisons has increased. (35) Recent studies revealed that there is a high prevalence of people suffering from mental disorders in USA, UK and New Zealand. For instance, in UK, rates of psychosis are reported as 4-10% for remanded prisoners and 2-7 % for sentenced prisoners. (36) These studies highlight the pattern that prisons are gradually becoming the preferred place for the disposal of mentally ill. (40)

A simple examination of the figures for England and Wales shows that the numbers of mental hospital beds and the numbers of prisoners have been inversely related in recent years. Figure 1 shows the rise in the number of prisoners between 1982 and 1997 and the fall in the number of mental hospital beds available over the same period. (The data for this figure were gleaned from various Health & Personal Social Services Statistics published by the Department of Health (England) and Home Office Statistical Bulletins, all available from HM Government Statistical Service.)

Fig. 1 Graph illustrating the increase in number of prisoners and decrease in number of mental hospital beds in England and Wales, 1982-1997 (40)

Nearly 33% of the prison population could be regarded as a psychiatric case. (37) In the UK, the availability of secure hospitals permits other alternative forms of management to choose from and forensic psychiatry represents a discipline that permits the link with community services. However, the policy of the government in the UK is that psychiatric services for offenders should be as far possible provided within the NHS. There are bountiful reasons for the imprisonment of mentally ill individuals, with public concern being most important. This is due to the stigma attached to ‘criminal lunatics’ and compounded by the ubiquitous portrayal of the mentally ill in the media. Other reasons include finance; imprisonment represents a cheaper option than other forms of management of mentally disordered offenders. (38)

American authors believe that their jails are replacing mental hospitals. Torrey (1995) conducted a survey in USA and concluded that:”quietly but steadily, jails and prisons are replacing public mental hospitals as the primary purveyors of public psychiatric services for individuals with serious mental illnesses in the US.” (39)14% of male and 25% female prisoners in San Diego County Jail were on psychiatric medication. 3 years back a report from jail officials revealed that the most common reasons for jailing seriously mentally disordered individuals were said to be because of assault, theft, alcohol and drug related crimes and trespassing.

With the emergence of the internet, obsessional harassers and sexual predators have found in cyberspace a major vehicle capable of helping them to satisfy their needs and potential victims tend to be more within their ambit. These include obtaining information, monitoring, contacting victims, developing fantasy, blackmailing and avoiding apprehension. Hence, there is a need for forensic psychiatrists to bridge the digital divide and become more familiar with computers and the internet so that relevant psychiatric evaluation of such subjects can be performed. (8)

Conclusion

Mentally ill patients are usually encompassed by taboos and the etiquettes stuck on any mentally disordered individuals make it even harder to seek help. If mentally disordered individuals are involved in criminal acts or any sorts of violent conduct or opprobrious behavior, they are likely to bear the contempt of the public. However, it is known to most that anxiety, sickness, accumulated stress caused by personal and professional issues can all potentially trigger mental problems to varied levels and consequences. Forensic psychiatry is a difficult specialty whereby healthcare professionals deal with mentally ill individuals who are offenders. The task of forensic psychiatrists sounds more herculean as compared to the general psychiatrist or even a doctor who helps a patient struggling in the penumbra between life and death. A lot of care is required when dealing with such patients because caring represents a psychologically supportive tool in the treatment of such patients and is tantamount to the evaporation of one’s prejudices to accept the patient as he is, listening to the mentally disordered individuals and to seek his reform from his starting point. Besides, a lot of resources must be targeted at encouraging research and the training of experts in this particular field of mental health.

Forensic psychiatry represents a challenging subspecialty of psychiatry that intersects with the legal and medical professions. It is one of the rare fields of medicine that is concerned with the assessment and management of mentally disordered offenders. The development of forensic psychiatry has been largely influenced by the Sefeloge case in the 1850s. Forensic psychiatrists need to possess a profound knowledge of criminology, law and psychiatry. Furthermore, forensic psychiatry is practiced in many countries such as US, UK, Canada, Israel, Australia and the Netherlands, but its practice varies slightly from one country to another due to different historical, developmental, legal and mental health systems. Likewise, cultural and religious issues also affect the practice of this subspecialty. The future status of treating mentally ill patients do not appear very bright because there is growing proclivity whereby jails are replacing mental hospitals in numerous countries and this is being done at a considerable pace. Still, the future is not so gloomy for mental health in general because a lot of research is underway, for instance improving the outcomes of drugs used in treatment of mentally ill individuals.

Kevin Mohee is a third year medical student at the University of Leeds
um06krm(at)leeds.ac.uk

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9. Abdalla-Filho E, Manoel Bertolote J. Forensic psychiatric systems of the world. Rev. Bras. Psiquiatr. vol.28 suppl.2 São Paulo Oct. 2006
10. Holmberg G, Kristiansson M. Contacts with public services, with special reference to mental health care, preceding a serious crime: A retrospective study of 268 subjects of forensic psychiatric investigations. International Journal of Law and Psychiatry, Volume 29, Issue 4, July-August 2006, Pages 281-288
11. Laks J,Werner J, Salvador de Miranda-Sá Jr L. Forensic psychiatry and human rights throughout life: children, adolescents and the elderly. Rev. Bras. Psiquiatr. vol.28 suppl.2 São Paulo Oct. 2006
12. Njenga FG. Forensic psychiatry: the African experience (commentary). World Psychiatry. 2006;5(2):97.
13. Bateman C. The insanity of a criminal justice system. S Afr Med J. 2005;95(4):208, 210, 212.
14. Velinov VT, Marinov PM. Forensic psychiatric practice: worldwide similarities and differences (commentary). World Psychiatry. 2006;5(2):98-9.
15. French L, Victimization of the mentally ill: An unintended consequence of deinstitutionalization, Social Work 32 (1987), pp. 502–505.
16. Pogrebin M R, Pool E D, Deinstitutionalization and increased arrest rates among the mentally disordered, Journal of Psychiatry & Law 15 (1987), pp. 117–127.
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This article has been written as part of the partnership between The Lancet Student and Asian Medical Students’ Association International. The 30th Asian Medical Students’ Conference will be held next week in Taiwan on the theme of ‘Stigmatised Illnesses: To understand, to accept, and to change’. We look forward to hearing about the conference, look out for the conference blog and podcast next week! Alistair Hustig, the Secretary of Academcis – Asian Medical Students’ Association International, has written this fantastic article on the theme.

‘Stamping out Mental Health Stigma’, NHS.

Stigma. This one word often represents the most crucial element effecting people living with a wide range of illnesses. It negatively impacts efforts to treat and prevent disease, and adversely affects individuals’ quality of life. Many illnesses have a high prevalence of stigma including mental illnesses, cancer, leprosy, and sexually transmitted diseases. However, the type of stigma varies with different conditions. This article highlights some causes and differences of stigma associated with mental health and HIV, as well as successful strategies of reducing its impact.

Definitions of stigma encompass social identity (deviance from what is normal), power discrepancies (that allow discrimination), and discrediting attributes that result in devaluation of people living with illnesses, such as those above (1,2,3). This often manifests itself in an external sense as discrimination, hatred, intolerance, rejection, and exclusion. However what is often under-recognised is the internal aspect of stigma. Internal manifestations can include self-loathing, shame, and self-blame, all of which are preyed upon when someone stigmatises (3,4). Stigmatisation can also extend to family, friends, and even to institutions and clinics which themselves perpetuate stigma. As a result anyone associating with patients, or visiting centres, can be dragged into the net of stigma.

People living with Mental Illness
People who have depression, schizophrenia, and other mental illnesses, commonly report stigma from both community and health professionals. Depression is a leading cause of disability effecting 121 million people worldwide (5). Schizophrenia affects millions of people. Of these, only 25% of those with depression, and 50% of those with schizophrenia who are in need of treatment are receiving appropriate therapy (5). These figures suggest that stigma, at least in part, may be having an affect on treatment of mental illness. The perception of depression as a weakness rather than an illness (6); or people with depression are dangerous, and ‘schizophrenics’ are violent (6,7) remains embedded in public opinion. These views are less shared with other common illnesses for example cardiovascular disease. Unlike mental illnesses, cardiovascular disease is less stigmatised at least in part because the aetiology, pathophysiology, and successful treatments are well known. The fear of the unknown may therefore contribute to stigma being ingrained in an illness. As a result people with the illness are afraid of disclosing to family and friends, and do not seek help where it would be of benefit (6). Health practitioners, even those in the field of mental health can also stigmatise through intensive use of language and labelling. Some are more empathic and understanding of the nature of the illnesses, but some practitioners continue to define their patient by their illness. The difference in language is powerful – a ‘schizophrenic’, whose behaviour defines them, versus a ‘person living with schizophrenia’, whose illness causes altered behaviour (7). This labelling may plague the patient as a ‘life sentence’ (7) reducing self-esteem, withdrawing social opportunities, and creating ongoing employment difficulties (8), ultimately ruining any chance of normality.

People living with HIV
It is estimated that around 33 million people worldwide are infected with HIV, with the majority in low- and middle-income countries (9). Of these, only 3 million were receiving appropriate anti-retroviral therapy as at December 2007 (9). Again one of the biggest issues preventing uptake is stigma. However, the stigma signature associated with people living with HIV is different to that explained for mental illness. Bos and colleauges (10) propose a model for stigmatisation of people living with HIV. They describe how perceived contagiousness (everyday contact, not just sex), perceived seriousness (life-threatening), personal responsibility (unsafe sex) and norm-violating behaviour (e.g. male-to-male sex, and intravenous drug use) contribute to increase fear and anger while decreasing pity for people living with the disease. Stigma also surrounds certain groups at increased risk, such as homosexuals, intravenous drug users, and sex-workers. This further stigmatises people living with HIV leading to amplified discrimination and negative social responses. As a result, people living with HIV have a decreased quality of life and are less likely to seek testing, treatment, and counselling, or disclose their status to potential support providers. This can result in advanced presentations with high viral loads, low CD4 counts, and opportunistic infections.

Strategies for Reducing Stigma
The need to address stigma is paramount in order to reduce prevalence and thus burden of illness (e.g. curbing the HIV epidemic), and increase treatment uptake. For mental illnesses, in particular depression, Barney and colleagues (6) suggest that blaming, avoiding, and labelling people living with mental illnesses must be addressed. Accurate knowledge and portrayals of survival and recovery, as well as the true risk to the community for these health conditions needs to be expressed by all means possible, especially the media.

Public disclosure of HIV status has been shown to have a beneficial impact to both the individual and the surrounding community (11). Individuals are often very scared and describe this as the most difficult and dangerous thing to do. Post-disclosure they feel empowered, released from a heavy secret, and less isolated and withdrawn, taking back control of their lives (11). To help facilitate this appropriate training and support needs to be given before disclosing to prepare for potential negative reactions from community members. However, public speaking regarding one’s positive living helps to make the community more aware and dispel myths around HIV, thus reducing stigma. This is echoed by studies involving public speaking by people living with HIV (11) and mental illness (12), which have shown improved attitudes among high school students to those living with the illness. Uniting all people with stigmatised illness would provide a voice that would be far too loud to ignore.

Access to relevant treatment that communities understand is effective and essential in any stigma reduction programme. The case of universal access to HIV therapy in Botswana (which has the 2nd highest prevalence), implemented in 2002, provides clear evidence of reducing stigma (13). Wolfe and colleagues (13) demonstrated pre- and post-implementation that only 31% of people had disclosed positive HIV status to family, and 5% to friends in 2001, compared with 90% and 55% respectively in 2004. Other examples of reduced stigmatising attitudes include an increase in the number of people that would care for a person living with HIV, accept them as a teacher and buy food from a shopkeeper with HIV.

Conclusion
Stigma and its consequences affect the course of illness for many millions of people worldwide. It provides an enormous barrier to all attempts to help people living with stigmatised illnesses. Stigma affects all, it endures, and it compromises survival and recovery of those most in need. We must strive to find new ways to abolish stigma, and thereby allow access to treatment and empowering positive living.

Alistair Hustig, hust0007@flinders.edu.au
Secretary of Academics – Asian Medical Students’ Association International
Australian Medical Students’ Association Councillor
Graduate Entry Medical Programme Year II – Flinders University, Adelaide, South Australia
Bachelor of Medical Science – Flinders University, Adelaide, South Australia

References
1. Joint United Nations Programme on HIV/AIDS (UNAIDS). Reducing HIV Stigma and Discrimination: a critical part of national AIDS programmes. [Online]. 2007 [accessed 20 June 2009]. http://data.unaids.org/pub/Report/2008/JC1521_stigmatisation_en.pdf.

2. Reidpath DD, Chan KY, Gifford SM, Allotey P. ‘He hath the French pox’: stigma, social value and social exclusion. Sociology of Health & Illness 2005; 27(4): pp. 468-489.

3. Courwright AM. Justice, Stigma, and the New Epidemiology of Health Disparities. Bioethics 2009; 23(2): pp. 90–96.

4. Cameron E. Witness to AIDS. Cape Town: Tafelberg Publishers Limited; 2005.

5. World Health Organization. Mental Health: Disorders Management. [Online]. 2009 [accessed: 21 June 2009]. www.who.int/mental_health/management/en/.

6. Barney LJ, Griffiths KM, Christensen H, Jorm AF. Exploring the nature of stigmatising beliefs about depression and help-seeking: Implications for reducing stigma. BMC Public Health 2009; 9(61).

7. Flanagan EH, Miller R, Davidson L. ‘‘Unfortunately, We Treat the Chart:’’ Sources of Stigma in Mental Health Settings. The Psychiatric Quarterly 2009; 80: pp. 55-64.

8. Corrigan P. How Stigma Interferes with Mental Health Care. American Psychologist 2004; 59(7): pp. 614-625.

9. Joint United Nations Programme on HIV/AIDS (UNAIDS). Report on the global HIV/AIDS epidemic. [Online]. 2008 [accessed 20 June 2009]. http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/2008_Global_report.asp

10. Bos AER, Schaalma HP, Pryor JB. Reducing AIDS-related stigma in developing countries: The importance of theory- and evidence-based interventions. Psychology, Health & Medicine 2008; 13(4): pp. 450-460.

11. Paxton S. The paradox of public HIV disclosure. AIDS Care 2002; 14(4): pp. 559-567.

12. Spagnolo AB, Murphy AA, Librera LA. Reducing Stigma by Meeting and Learning from People with Mental Illness. Psychiatric Rehabilitation Journal 2008; 31(3): pp. 186-193.

13. Wolfe WR, Weiser SD, Leiter K, Steward WT, Percy-de Korte F, Phaladze N, Iacopino V, Heisler M. The Impact of Universal Access to Antiretroviral Therapy on HIV Stigma in Botswana. American Journal of Public Health, 2008; 98(10): pp. 1865-71.

Sandra Zaeh writes on the the mental health challenges in Sierra Leone. 

By any Western account, the mental health system in Sierra Leone is struggling.

With one trained government psychiatrist, little funding for psychiatric drugs and mental health facilities, and few opportunities for mental health care outside the capital of Freetown, the majority of mentally ill patients are beyond the reach of biomedical care for mental disorders.

To fill the void, Sierra Leoneans turn to alternatives like traditional healing and spiritual practices to address their mental health needs, options that even Western-trained experts consider crucial to maintaining the country’s mental health. And yet, the balance is tenuous – and, without an infusion of financial and human resources, may not be sustainable. (more…)

Like many developing countries Sri Lanka has suffered from chronic underinvestment in psychiatric services. The need for locally based services was made all the more apparent amid the devastation of the Boxing Day Tsunami of 2004. Mehrunisha Suleman, Matthew Fittall and Justin Loke spoke to two doctors about the process of reform, and the role that medical students have played in the wake of the tsumami.

(more…)