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Table of Contents
Year : 2022  |  Volume : 36  |  Issue : 1  |  Page : 39-43

Psychiatric evaluations in offenders with mental illness: A case series

1 Department of General Psychiatry, Taoyuan Psychiatric Center, Ministry of Health and Welfare, Taoyuan County, Taiwan
2 Department of Psychology, Taoyuan Psychiatric Center, Ministry of Health and Welfare, Taoyuan County, Taiwan
3 Department of General Psychiatry, Taoyuan Psychiatric Center, Ministry of Health and Welfare; Department of Psychology, Chung Yuan Christian University, Chung-Li, Taoyuan County, Taiwan

Date of Submission15-Oct-2021
Date of Decision23-Nov-2021
Date of Acceptance25-Nov-2021
Date of Web Publication26-Mar-2022

Correspondence Address:
Chia- Hsiang Chan
No. 71, Longshou Street, Taoyuan District, Taoyuan 330
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/TPSY.TPSY_5_22

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Background: The relation between mental illness and criminal offenses is controversial. In Taiwan, offenders with mental illness may be sentenced to custodial protection. Nevertheless, the recidivism rates remain high in such populations. Factors associated with recidivism among those offenders warrant further exploration. Methods: We retrospectively identified five persons with mental illness who had repeated forensic psychiatric evaluation for at least three times through reviewing forensic psychiatry records over the past decade at a psychiatric center. The related sociodemographic characteristics and psychiatric profiles in the 22 offenses were also collected and correlated with verdicts. Results: Those five offenders had family and personal histories of mental illnesses. They were relatively young at the first offense and unemployed, unmarried during the period of committing the offenses. Some offenders had a history of substance use, self-harm attempts, other criminal behaviors, and poor adherence to treatments before the offense. All the concluded characteristics of forensic psychiatric evaluations were consistent with the court judgments. Conclusion: Social dysfunction, poor adherence to treatments, history of substance use, and previous criminal records were prominent among those five repeated offenders.

Keywords: criminal offense, custodial protection, mental illness, recidivism

How to cite this article:
Lin CH, Hsieh WC, Liu HW, Chan CH. Psychiatric evaluations in offenders with mental illness: A case series. Taiwan J Psychiatry 2022;36:39-43

How to cite this URL:
Lin CH, Hsieh WC, Liu HW, Chan CH. Psychiatric evaluations in offenders with mental illness: A case series. Taiwan J Psychiatry [serial online] 2022 [cited 2023 Jan 31];36:39-43. Available from: http://www.e-tjp.org/text.asp?2022/36/1/39/341037

  Introduction Top

A consensus has yet to be reached on the association between criminal behavior and mental illness [1]. The notion that people with severe mental illness can be dangerous might have been mediated through previous contacts or information access [2]. Under varying law enforcement and socioeconomic conditions, about 20%–40% of patients with severe mental illness have a contact with the police at least once in their lifetime; furthermore, more than 50% of police officers have reported receiving calls involving mentally ill individuals at least once a month, and the reported issues are involved disruptive behavior, violence, or substance use [3].

Clinicians suggested that for offenders with mental illness (OMI), the role of mental health system should not be completely replaced with the criminal justice system [4]. Some nations adopt secure hospital care for those OMI, the cost of which can be higher than that of incarceration [5]. But repeated offenders are less prevalent among patients discharged from secure hospitals than released prisoners, implying that changeable factors can be amended through mental health interventions [5]. In Taiwan, according to the Criminal Code of the Republic of China Article 87, those offenders with mental illness can be committed to psychiatric hospitals for custodial protection after execution of the punishment. But a study showed that a half of those offenders with mental illness are prosecuted again within three years of discharge from psychiatric hospitals [6]. The possible factors associated with recidivism among those with mental illness have been previously reviewed as male gender, younger age upon first appearing in the court, substance use, personality disorder, or family dysfunction [5],[7]. To reduce the rates of recidivism and develop individualized intervention programs for offenders with mental illness (OMI) in Taiwan, the characteristics and risk factors associated with domestic OMI samples warrant exploration.

Here, we present five persons with mental illness who had repeated psychiatric evaluation, referred by the courts over the past decade. The association of mental illnesses with criminal behavior has been ascertained through reviewing forensic psychiatric evaluation reports.

  Methods Top

We reviewed the forensic evaluations of 700 criminal cases referred to the Taoyuan Psychiatric Center (TYPC) from October 2009 to January 2021. Most of those cases were referred to the TYPC by the Taiwan Taoyuan District Court. Two well-experienced forensic psychiatrists were included in each interview for diagnostic validation using the Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR), or DSM-5 for all offenders.

Sociodemographic data and clinical profiles including gender, birth date, identification number, educational years, childhood adversity, job status, onset of psychiatric symptoms, age of first psychiatric visit, previous admissions, previous mainline medications, and adherence to treatments before offense were collected retrospectively from medical records at the TYPC; we also correlated with the descriptions in forensic evaluation reports. The details of the offense, symptoms upon the offense, substance use before the offense, criminal history, diagnoses, and inferred mental status upon the offense were reviewed and collected from forensic evaluation reports. The court decisions of the mental status upon the offense in each criminal case were confirmed if publicly available verdicts online in Law and Regulations Retrieving System of Judicial Yuan. In the process of organizing the above information, we identified five repeated offenders with mental illness based on the identification number, who received at least three times of forensic evaluations during the past decade due to different offenses. The study protocol was approved by the institutional review board of the TYPC (IRB protocol number = B20210722-2, and date of approval = September 6, 2021) with the waiver of obtaining signed informed consents from those patients.

  Results Top

We identified five persons with mental illness who had repeated psychiatric evaluations [Table 1] for at least three times in the TYPC. Four of them were men. The mean age at initial offense and that at subsequent offenses after forensic psychiatric evaluations were 20.2 and 36.3 years, respectively. We observed the mean education years to be 12.4 years. Of the repeated offenders, four were victims of childhood adversities. All repeated offenders with mental illness were unemployed and unmarried, and two of them lived alone around the time of committing the offenses. All had familial and personal histories of psychiatric illnesses. Moreover, three of them had substance (including glue, ketamine, and amphetamine) use disorders. Four had a history of violence, and three of them had attempted suicide.
Table 1: Sociodemographic data of five offenders with mental illness

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[Table 2] lists 22 offenses made by the identified repeated offenders with mental illness and the corresponding clinical presentations. Most of the patients showed poor adherence to medical treatment for months before committing their offenses. Two offenses occurred in jail. About a half of the offenses were involved theft. Of the 22 offenses [Table 2], four were related to concurrent substance intoxication and to psychotic symptoms. But 10 offenses were not directly related to active psychotic symptoms. The remaining eight offenses were related to positive psychotic symptoms and were considered to be associated with diminished responsibility. All summaries drawn from the forensic evaluations were consistent with court verdicts. Offenders in only 2 of the 22 cases were sentenced to custodial protection, but they made another offense before the execution of the sentence.
Table 2: Twenty-two offenses of five offenders with mental illness reported after forensic psychiatric assessments

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  Discussion Top

As shown in [Table 1], we report the cases of five repeated offenders with mental illness who were referred to forensic psychiatric evaluation by the courts. We identified some features of those offenders that require clinical and public attention. First, recidivism was frequent in those five offenders, with a median interval of 1.2 years. Second, the identified offenders had a familial and personal history of mental illness along with poor social support and nonadherence to medical treatment around the time of commitment of offenses. Third, the problems associated with the offenders, including substance use, occupational dysfunction, and social dysfunction, were unresolved even after serving the sentences. For the five offenders, systematic surveillance by family members, judiciary systems, or clinical practitioners might not be effective in preventing recidivism. Finally, the conditions of self-harm attempts among them could not be neglected, highlighting the importance of evaluation of suicide risk among those offenders with mental illness.

A systemic review and meta-analysis revealed that the worldwide pooled prevalence of psychotic disorders in male prisoners was about 3.6%, higher than that in the general population [8]. But a substantial proportion of prisoners with schizophrenia does not receive treatment during incarceration, and in England, where prisoners are monitored with extensive support from the community, less than a quarter of prisoners with psychotic disorders efficiently received community mental health care [9],[10]. If offenders with mental illness are released into the same stressful environments without enough support, adverse conditions such as homelessness, substance use, and chaotic interpersonal relationship can trigger the relapse of mental illness and recidivism [5],[7]. To general psychiatric units or community services alone, it has been challenging to stabilize those repeated offenders with complicated disadvantages.

In Japan, OMI had been treated in general psychiatric hospitals along with other patients until 2003, when the Medical Treatment and Supervision Act (MTSA) was passed. After the legislation of the MTSA, Japanese facilities for offenders with mental illness collaborated with rehabilitation coordinators to effectively reduce recidivism rates [11]. In the United States, Forensic Assertive Community Treatment programs are being implemented; such programs primarily involve the delivery of comprehensive health-care services to address untreated illnesses and establishment of criminal justice agencies to prevent homelessness or imprisonment [12]. Coordination between assertive community intervention and legal leverage is essential, partially because those offenders with mental illness may ultimately need to stay on continued medication to remain asymptomatic [13]. Nevertheless, recidivism is not always directly related to the offenders' mental illness [14].

A previous study revealed that compared with prisoners without mental illness, prisoners with severe mental illness tended to be imprisoned again within 18 months of release [15]. Another study demonstrated that effective predictors of recidivism are young age, early age of offense onset, and a concurrent diagnosis of personality disorder [5]. If an offender has a co-occurring substance use disorder, the recidivism rates can increase substantially [16]. A British prospective cohort study reported that the recidivism rate for those offenders with mental illness is about 15% within 2 years of discharge from secure hospitals; this is strongly related to previous offenses, most of which are involved sexual abuse or substance use problems [17]. Furthermore, another long-term cohort study including 550 repeated offenders indicated that 32% of the offenders eventually committed suicide, 49% of those discharged are convicted again, and nearly two-fifth of the offenders are admitted into secure hospitals again within 20 years of follow-up [18], implying that the possible “static” risk factors are mediated the long-term criminogenic tendencies in the offenses among those repeated offenders [5].

Study Limitations

According to our review of the literature, our study is among the few Asian studies concentrating on recidivism among offenders with mental illness. Nevertheless, our study has three limitations:

  • Our cases were selected from offenders referred for forensic evaluations, which may have excluded those who reached settlements or applied for summary judgments. Not all offenders with suspected mental health problems were referred for forensic evaluations by the courts. Therefore, we need to question about the representations of those patients in this study.
  • The offenders were forensically and psychologically evaluated a couple of months after the actual events of offense and occasionally received interventions from the staff of the mental health system. The recall bias or external incentives from the offenders during evaluations could not be neglected [19].
  • Some individuals with disturbing behaviors or misdemeanors might be sent to psychiatric treatment instead of being prosecuted eventually. Experts may underestimate the influence of mental illness on individuals committing offenses.


Among the identified five offenders with mental illness in our study, they were younger in age at the first offense, poor social support, substance use, previous criminal records, and poor adherence to treatment were clinically prominent and characteristic. The present study can provide valuable information for mental health professionals, legal department staff, and policymakers in developing further research on integrated strategies for reducing recidivism among offenders with mental illness.

  Financial Support and Sponsorship Top


[TAG:2]Conflicts of Interest[/TAG:2]

The authors declare no conflicts of interest in writing this report.

  References Top

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Fazel S, Seewald K: Severe mental illness in 33,588 prisoners worldwide: systematic review and meta-regression analysis. Br J Psychiatry 2012; 200: 364-73.  Back to cited text no. 8
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Fujii C, Fukuda Y, Ando K, et al.: Development of forensic mental health services in Japan: working towards the reintegration of offenders with mental disorders. Int J Ment Health Syst 2014; 8: 21.  Back to cited text no. 11
Lamberti JS, Weisman R, Faden DI: Forensic assertive community treatment: preventing incarceration of adults with severe mental illness. Psychiatr Serv 2004; 55: 1285-93.  Back to cited text no. 12
Lamb HR, Weinberger LE, Gross BH: Community treatment of severely mentally ill offenders under the jurisdiction of the criminal justice system: a review. New Dir Ment Health Serv 2001; 90: 51-65.  Back to cited text no. 13
Skeem JL, Winter E, Kennealy PJ, et al.: Offenders with mental illness have criminogenic needs, too: toward recidivism reduction. Law Hum Behav 2014; 38: 212-24.  Back to cited text no. 14
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Tzeng SR, Chen CH, Tan HK: Malingering and malingering by proxy in an adult patient: the need for inpatient forensic evaluation. Taiwan J Psychiatry 2011; 28: 60-1.  Back to cited text no. 19


  [Table 1], [Table 2]


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