Services for released prisoners should address the many causes of reoffending
Authors: Louis Appleby, Alison Roscoe, Jenny Shaw
Journal: The Lancet Psychiatry (2015)

Reoffending is complex. It is linked to many individual and social factors, including personality, substance misuse, social support, employment, and education; factors that might interact or form a causal pathway. This complexity gets in the way of prevention—despite political attention, reoffending in England and Wales remains high, with 45·4% of adult offenders and 66·5% of juvenile offenders committing another offence within 12 months of prison release.1Ministry of JusticeProven re-offending statistics quarterly bulletin. October 2012 to September 2013, England and Wales. Ministry of Justice, London2015Google Scholar This complexity is also why the role of mental illness has been hard to specify—many of the risk factors for reoffending are common in people with mental illness. What, therefore, is the role of psychiatric disorders themselves? Chang and colleagues2Chang Z Larsson H Lichtenstein P Fazel S Psychiatric disorders and violent reoffending: a national cohort study of convicted prisoners in Sweden.Lancet Psychiatry. 2015; (published online Sept 3.)http://dx.doi.org/10.1016/S2215-0366(15)00234-5Google Scholar aim to address this issue with their study in The Lancet Psychiatry, examining the role of mental disorders in violent reoffending by released prisoners using Swedish population databases that record convictions and social circumstances, and a national psychiatric case register. Studies based on large datasets of this kind are highly informative because they have access to large numbers of cases in whole populations, but they tend to be limited by a restricted number of explanatory variables. This limitation calls for caution in interpretation, especially in understanding of causality in complex outcomes. Chang and colleagues have focused on one type of variable—psychiatric disorders, broadly defined to include substance misuse disorder—and have adjusted for several others that were available to them: marital status, employment, education, and immigration, although not personality, housing, living circumstances, or ethnic origin. They note that violent reoffending is linked to mental health disorders, especially bipolar disorder, an association that remains after adjustment for sociodemographic variables. Drug and alcohol misuse are also related to reoffending, but comorbid substance misuse does not explain the association with mental illness—the same research group has previously reported that serious violence in schizophrenia is mainly attributable to substance misuse comorbidity.3Fazel S Långström N Hjern A Lichtenstein P Schizophrenia, substance abuse, and violent crime.JAMA. 2009; 301: 2016-2023Crossref PubMed Scopus (485) Google Scholar They find a population attributable fraction for psychiatric disorder of about 20% in men and 40% in women: this value is the proportion of violent reoffending that could be attributable to psychiatric disorder if the relation was causal and it therefore represents the potential for prevention that could be achieved through improved mental health treatment for prisoners. Few topics in mental health are more sensitive than the extent to which mental health disorder is a cause of violence. People with mental illness who, in their daily lives, face obstacles to employment, relationships, and full participation in society blame the reported link to violence for stoking public fear and discrimination. Anyone carrying out research into this topic is acutely aware of the need to avoid adding to the stigma. Our research group, which reports on homicides by mental health patients in the UK, has regularly published balancing studies, findings from which show that patient homicide figures have fallen,4Appleby L, Kapur N, Shaw J, et al. The national confidential inquiry into suicide and homicide by people with mental illness (2015). Annual report 2015: England, Northern Ireland, Scotland and Wales. Manchester, University of Manchester, 2015.Google Scholar a high risk exists of patients with mental health problems being victims of homicide,5Rodway C Flynn S While D et al.Patients with mental illness as victims of homicide: a national consecutive case series.Lancet Psychiatry. 2014; 1: 129-134Summary Full Text Full Text PDF Scopus (27) Google Scholar and people who kill unknown members of the public are far more likely to be drunk than mentally ill.6Shaw J Amos T Hunt IM et al.Mental illness in people who kill strangers: longitudinal study and national clinical survey.BMJ. 2004; 328: 734-737Crossref PubMed Scopus (45) Google Scholar The conclusion by Chang and colleagues that mental illness is a major cause of violent reoffending in prisoners will therefore be unwelcome in the mental health community at a time when surveys suggest that public attitudes to mental illness are improving.7TNS BNRB Attitudes to mental illness 2013 research report. TNS BMRB, London2014Google Scholar A view that violence and mental illness is a subject too stigmatising to feature in a leading academic journal has even been put forward (as a reviewer of one of our studies advised). But avoidance of the issue will not reassure the public. They are concerned, not just about mental illness, but about what they see as gaps in the system of care that could leave patients and others at risk. Chang and colleagues call for better mental health care for prisoners before and after release than is offered at present, and no one could disagree that this improvement is needed. Yet how much effect it can have on reduction of reoffending and its annual cost to the England and Wales economy of £9·5–13 billion8National Audit OfficeManaging offenders on short custodial sentences. Ministry of Justice, London2010Google Scholar is less clear. In view of the absence from this study of the several key variables linked to offending mentioned above, the contribution of psychiatric disorder—and its reduction from treating it—might well be substantially less than the 20% in men and 40% in women reported by Chang and colleagues. And if the causal factors are interconnected, treatment of mental illness might be effective only if the poor housing, substance misuse, or absence of a job that are so common in released prisoners are also addressed. Governments and some justice agencies might be tempted by the simple message that the answers to issues in the criminal justice system lie with mental health services. Meanwhile, the claim that mental illness is a direct cause of violence will make uncomfortable reading in mental health. The implication of this study lies between the two: treatment of psychiatric disorders in prisons and on release is crucial, but will not be enough to bring about a major reduction in violent crime. Comprehensive packages of treatment and social support are needed that hold a therapeutic mirror to the complexity and adversity of offenders' lives. LA is the Director of, AR is a Research Associate at, and JS is the Head of Homicide Research for the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. Psychiatric disorders and violent reoffending: a national cohort study of convicted prisoners in SwedenCertain psychiatric disorders are associated with a substantially increased hazard of violent reoffending. Because these disorders are prevalent and mostly treatable, improvements to prison mental health services could counteract the cycle of reoffending and improve both public health and safety. National violence prevention strategies should consider the role of prison health. Full-Text PDF Open Access