Psychiatry Reforms and Increasing Criminal Behavior of the Severely Mentally Ill: Any Link?

Abstract

During the last decades of the 20th century, general mental healthcare underwent fundamental changes in all countries of the Western world. Despite all doubtless improvements for the majority of the mentally ill, many countries report on a substantial increase of admissions of mentally disordered offenders to forensic hospitals. Possible relations between these findings and the introduction of psychiatry reforms are under permanent discussion. However, the more or less ubiquitous increase of forensic hospital beds seems to conflict with the heterogeneous economic and legal preconditions for the reforms and the remarkable differences concerning details of service provision, access to medical insurance and social support in various parts of the world. We tried to find an explanation for these findings and to formulate a hypothesis which is able to resolve the seeming contradictions. Epidemiological data from Austria on psychiatric service provision and data from criminal statistics since 1970 were taken from several national sources and analyzed with regard to possible associations. Lack of mental hospital beds, insufficient provision of outpatient care, increasing “liberalism” with regard to involuntary admission to inpatient treatment or a general trend towards risk containment were not able to sufficiently explain the increase of forensic hospital beds. Rather, the rising incidence and prevalence rates of mentally disordered offenders not guilty by reason of insanity (NGRI) were associated with a marked reduction of time under civil commitment in patients posing danger to others. However, this factor represents a mere epiphenomenon and has to be understood as a proxy for the changed attitude of mental health professionals towards a subgroup of violent patients whose sufficient treatment is not integrated into the therapeutic concepts of modern mental healthcare. This may be the consequence of the societal changes in all countries of the Western world during the last 50 years.