| 10/10/2003 Debate about psychiatry
continues in Sweden
In the wake of two extreme high-profile cases this summer in Stockholm,
when individuals with serious mental disorder committed horrendous,
unprovoked violent crimes (the Åkeshov and the Gamla
Stan cases), a debate over the role of psychiatry has erupted
in Sweden.
One issue is whether deinstitutionalisation has led to an increasing
number of people with mental disorders on the streets, who pose
a danger to society. This deinstitutionalisation followed a reform
in the 1990s that led to a two-thirds reduction in the number of
psychiatric hospital beds. People may wonder whether this was a
beneficial move. In addition, the closing down of inpatient facilities
was not matched by a build-up in outpatient services for these patients,
as originally intended. Consequently, it is argued that many people
have been left to their own devices in the community, with consequences
such as homelessness, increased suicide risk, and increased risk
for crime.
More recently, on September 10th, Sweden's foreign ministry Anna
Lindh was stabbed with a knife by an unknown assailant in the Stockholm
city shopping centre NK. She had extensive surgery for the duration
of the evening and night, but died in early morning, September 11th
- as if this particular date needed any more emotional baggage.
A 24-year old man has been held in custody for the killing for
some time, and he was recently indicted. Although the motive for
his action is not clear, should he be proven guilty as charged,
again the role of mental disorder as a vehicle for unprovoked, severe
violence is on the agenda in the Swedish news media.
NEWS FLASH 10/10/2003
The Government this week appointed Dr. Anders Milton to
lead a special task force on psychiatry as a consequence of the
recent debate. One of the critical issues of Mr Milton’s enquiry
will be the role that mental health services play in the prevention
of violence and the protection of third parties. Specifically, he
is to investigate if and why efforts between different services
are sub-optimally co-ordinated. Many patients are stuck in a negative
pattern where they cycle between different health and social services,
without any single one agency assuming the responsibility for them.
Researchers at CVP express concern about the ongoing debate. On
the one hand there is now an interest in these issues – which
is long overdue, says Dr. Martin Grann, researcher
at CVP. It is a shame that it takes a series of such extreme incidents
to make the debate occur. Moreover, some of the things being said
in the debate are unfortunate and idiosyncratic. Some people on
the margins of psychiatry would like to turn the clock back and
lock everyone up, and increase psychiatrists’ means for coercion,
says Dr Grann. These “solutions” might seem appealing
but are completely out of touch with reality. One can only hope
that people in general see through the media hype.
But unfortunately there is a great risk that a stereotypical and
stigmatising image of people who suffer from mental disorders now
spreads among the public. This inaccurate image is that mentally
disordered people who were previously locked-up are now, as a result
of a failed reform in the mid 90s, dwelling in the community, posing
a threat to us all.
There is however no sound scientific support that violence has
increased among this group of patients, or even that violence is
common among the mentally disordered. In ongoing epidemiologic studies
at CVP, Dr Grann and Dr. Seena Fazel, forensic
psychiatrist from the University of Oxford, U.K., and research affiliate
at CVP, have shown that only some 6% of all violent crime committed
in Sweden are perpetrated by people who are identified with a psychosis
by mental health services. Of these 6% the group suffering from
schizophrenia was as low as 2%, Dr Fazel says.
However, the proportion of people with severe mental disorders
is higher for the most severe type of violence, homicide. For homicide
offenders, a rate of psychosis of 25% (11% schizophrenia) was found.
This research was based on information gathered on 1625 of the total
of 2005 homicides we investigated. However, with these psychiatric
conditions it is unlikely that we would miss many cases, explains
Dr Fazel.
Due to the demands of the news media, it is unfortunate that homicide
takes so much attention, comments Dr. Grann. But Sweden’s
homicide rate is exceedingly low, among the lowest in the world.
We have just over 100 cases per year in a population of nearly 9
million. The absolute number of mentally disordered people committing
murder is thus very low. It is a pity that we do not see more debate
about violence in general in society. After all, assaultative crimes
are much bigger public health challenges, says Dr Grann. “I
am overall pleased with the nuanced manner our research data was
recently reported, although the phrasing of headlines was not unfortunate.
Personally I feel that headline phrasing and the use of certain
images with these stories are two of the issues where news media’s
role needs to be critically discussed,” adds Dr Grann.
In this over-heated climate, people look for simple solutions to
complex problems, says Dr. Niklas Långström,
child- and adolescent psychiatrist and associate professor at CVP.
Especially now after the Anna Lindh homicide.
One aspect is over the role the Security Police (the Swedish equivalent
of Secret Service), the other is about cutting down on inpatient
mental health care. “But returning to the old days with its
large mental institutions and indefinite hospitalisations pose no
solution to our problems”, says Dr Långström.
After all, violence is an issue that is not only psychiatric in
nature, says Drs Grann and Långström. Violence is a complex
social, psychological, biological and political phenomenon, much
of which we don’t understand. Understanding and preventing
violence requires broad, cross-disciplinary and multi-agency efforts.
And much more research.
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