The increase in the number of homicides committed by people with schizophrenia, revealed in the 2009 Annual Report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, is a cause for concern. 1 The report suggests that the increase is accounted for by individuals not classified as ‘patients’, i.e. those who have not been in contact with services in the past 12 months. If the total of the data is represented in the report, then one should be able to derive the number of ‘non-patients’ by simply subtracting the ‘patients’ from the total of the schizophrenia homicide group. That resulting figure does not appear to support the hypothesis. It appears to show that the entire increase is due to ‘patients’. This increase may be as a result of follow-up failings.
Assessing patients for mental health review tribunals, I have noted that many teams often simply discharge patients when they do not cooperate with follow-up. The ‘positive attitude of hope and recovery’, adopted by some community teams and encouraged in New Ways of Working, 2 fails to acknowledge the typically chronic or relapsing course of schizophrenia. New Ways of Working also appears to discourage consultant psychiatrists from engaging in long-term follow-up by talking of a ‘shrinking and more focused role for senior professionals, shedding repetitive activities or doing them more smartly’. These approaches and the fragmentation of services into myriad teams risk losing opportunities to form and maintain therapeutic relationships with patients and their families, and to gain understanding of the long-term course of patients' illnesses. It can subsequently become a bewildering task for families of discharged patients, or for concerned others, to receive help. When they do make contact, this will often be with professionals unknown to the patient and to whom the patient is unknown.
Given the increased investment and increased numbers of psychiatrists documented in New Ways of Working, it is difficult to see why psychiatrists and other professionals should have less time to allocate to the important task of maintaining links with this high-priority group. The 2007 progress report on New Ways of Working states: ‘The aim is to achieve a cultural shift in services that enables those with the most experience and skills to work face to face with those with the most complex needs’. 3 Schizophrenia is a severe and usually chronic or recurrent illness associated with a high suicide risk and relatively high homicide risk. It is commonly associated with substance misuse. Long-term prophylactic medication and psychological and psychosocial interventions can reduce relapse rates. Long-term medical treatment carries risks of adverse effects. Consultant psychiatrists are commonly among the longest-serving members of their teams. The complex elements of schizophrenia and the advantages of long-term follow-up provide an important and valid role for psychiatrists.
The Inquiry should gather data on how many of those with schizophrenia, committing homicide, have been under psychiatric care, how and why they ceased to be so, and in how many cases others had been trying to involve psychiatric services prior to the homicide. There may be a lesson that long-term follow-up of patients with schizophrenia is justified, even if the patient appears well.