Pharmacotherapy to reduce violent offending? Offenders might be interested

Violence is responsible for significant morbidity and mortality, and its prevention is a major public health imperative. Evidence from a range of sources implicates dysregulation of serotonin as an important biological mechanism that may underlie some or even much impulsive or reactive violence (Coccaro et al., 2015). Selective serotonin reuptake inhibitors (SSRIs) have been shown to reduce impulsivity and violence (Coccaro et al., 2015) and, if taken by repeat-violent offenders, could potentially reduce violent crime. How could definitive evidence in support of such an approach be obtained? In a small open-label study, we examined the feasibility of using an SSRI to treat impulsive men with prior convictions for violence (Butler et al., 2010). In all, 34 repeat violent offenders were all administered sertraline 100 mg/day, and we observed significant reductions from baseline to 12 weeks across measures of impulsivity (35% reduction), irritability (45%), anger (63%), assault (51%), verbal assault (40%) and indirect assault (63%). The lack of placebo controls and of a robust offending-related outcome following treatment were important limitations of that study, and a formal, randomised, placebo-controlled trial with well-defined outcomes seemed to be indicated. But how interested would impulsive violent offenders be in participating in such a study? An ethics variation was obtained as part of the 2009 NSW Inmate Health Survey to include questions to a sub-sample of 135 prisoners with scores on the Barratt Impulsiveness Scale (BIS) of 70 or higher. It is the responses from these impulsive individuals that we focus on in the following.

Questionnaire respondents were informed that we wished to determine their interest in participating in a formal study to evaluate the use of pharmacotherapy to ‘reduce anger, intense irritability and a tendency to physical violence’. Among the 135 men with BIS scores >70, 70 (52%) indicated that they would be interested in finding out more about such a study. Of those 70 individuals, 56 (80%) responded positively to the question, ‘Would you still be interested if this trial involved a 50% chance of receiving a placebo (i.e. a “sugar pill”) and lasted for approximately 12 months?’

In our view, these results imply an important level of insight among many offenders as to the negative consequences of their impulsivity. In addition, the results imply some significant levels of interest among offenders in the conduct of a formal study to evaluate the potential benefits of a drug treatment to reduce problematic violence.

Biological approaches to the study of criminology are, once again, challenging and enriching the field, and the evaluation of pharmacotherapy as a means of reducing some forms of crime sits comfortably within the conceptual frameworks of the recently named disciplines of biosocial- and neurocriminology (Glenn and Raine, 2014; Rocque et al., 2012). Rates of traumatic brain injury, psychiatric illness and neurodevelopmental abnormalities (including attention deficit disorder and intellectual disabilities) are vastly overrepresented within offender populations (Fazel and Danesh, 2002). By no means have all individuals with such conditions been appropriately diagnosed or optimally managed prior to the onset of offending behaviours; in view of the potential for such conditions to impact behaviour, it may be hard in individual cases to exclude their causal or at least contributory associations with offending. If neuropsychiatric disorders of these kinds are first detected in the context of contact with the justice system, in an ideal world, optimal treatment would be offered and, if it included pharmacotherapy, such treatment would not be controversial. Sadly, resource limitations relating to medical/psychiatric assessment and management in forensic settings mean that the rates of detection, diagnosis and comprehensive, optimal management of such conditions is, in most settings, likely to be low. If well-designed studies were to demonstrate that lower rates of recidivism could be achieved by better treatment of offenders with impulsive violent disorders, more resources could be directed at this issue.