Suicidal Behavior among Forensic Patients in Japan: Risk Factors and Implications for Treatment

doi:10.21203/rs.3.rs-5034681/v1

Purpose In Japan, the Medical Treatment and Supervision Act (MTSA) was enacted in 2005 to provide intensive interventions for forensic patients. Despite this, these individuals face considerable challenges with social reintegration and exhibit a higher suicide risk. Consequently, identifying risk factors for suicide among forensic patients is crucial. Despite the clear need, few studies have examined these risk factors in Japan.

Methods We compiled a near-comprehensive database covering 12 years of data on Japanese forensic outpatients. Using a generalized linear model (GLM), we investigated the relationship between suicidal behavior—including both attempted and completed suicides—and several variables. These variables included the outpatient pathway as defined by the law, psychiatric outpatient/inpatient treatment history, diagnoses of schizophrenia or mood disorder, type of crime committed, and type of victim involved.

Results Our analysis included data from 2,263 Japanese forensic outpatients. We observed suicidal behaviors in 6.9% of these patients, with 1.5% completing suicide. Risk factors for suicidal behavior included being a direct outpatient (odds ratio [OR] = 1.63, 95% confidence interval [CI]: 1.14–2.34), having a history of outpatient treatment (OR = 1.92, 95 %CI: 1.07–3.48), and being arrested for arson (OR = 2.24, 95% CI: 1.33–3.76). Conversely, a diagnosis of schizophrenia was linked to a decreased risk of suicidal behavior (OR = 0.61, 95% CI: 0.39–0.95).

Conclusion Given that forensic patients are at a higher risk of suicide compared to the general population, it is imperative to consider risk and protective factors when intervening with these individuals.

Psychiatry

suicide

suicidal behavior

forensic patient

schizophrenia

The Medical Treatment and Supervision Act (MTSA) was enacted in Japan in July 2005. This law aims to establish a framework that facilitates the social reintegration of individuals who have committed serious crimes under conditions of insanity and to prevent recidivism by improving their medical conditions. Since the law's implementation, approximately 250 people have been treated under this system each year [1]. The MTSA enables district courts to issue orders for forensic patients, mandating either hospitalization (“inpatient treatment order”) or regular visits to a government-designated medical facility (“direct outpatient treatment order”). Additionally, courts can authorize the discharge of inpatients, after which their care may transition to outpatient treatment (“indirect outpatient treatment order”) or conclude with a transfer to general psychiatric care. Patients under an outpatient treatment order undergo regular outpatient treatment while also being monitored by the probation office for mental health. Once their condition stabilizes and their risk of recidivism is deemed minimal, these individuals are returned to the district court to seek approval for terminating their treatment and reintegrating into society [2].

The MTSA facilitates the social reintegration of forensic patients. However, supporting this process is challenging, and common barriers globally include recidivism [3, 4] and suicide [5-7]. Prior research has pinpointed risk factors for problematic behavior in forensic patients, such as a young age at the time of their first crime and substance abuse [8, 9], a history of inpatient psychiatric treatment [10], and a history of minor offenses [9]. Additionally, risk factors for suicide and self-harm among these patients include neurodevelopmental disorders [11], impulsivity and antisocial behavior [12], and adverse childhood experiences [13, 14]. Cognitive factors, such as impaired social cognition, are also linked to suicide risk in this group [15]. Despite the identification of these risk factors, studies specifically analyzing risk factors for suicide among forensic patients are scarce, underscoring the urgent need for more research to effectively prevent suicide in this vulnerable population.

Specifically, suicides among Japanese forensic patients have not been adequately researched. A 2019 study by Takeda et al. [7] identified being female as a risk factor for suicide among this demographic; however, the study was limited to only 966 patients. Given that suicide is preventable, it is imperative to examine larger datasets to facilitate early intervention and the development of effective prevention strategies.

To address this research gap, we compiled a nearly comprehensive database of forensic outpatients under the MTSA from July 2005 to March 2018. Our study aims to identify risk factors for suicidal behavior, including both attempted and completed suicides, among Japanese forensic patients.

2-1. Research participants

A survey was mailed to outpatient medical institutions designated by the Ministry of Health, Labour and Welfare. Out of 601 designated institutions nationwide (as of December 2017), 543 (90.3%) agreed to participate in the study. Data were collected from 2,272 forensic patients who received outpatient treatment between July 2005 and March 2018, including those patients without missing values in the analysis.

2-2. Data collection

The staff of the designated medical institutions indirectly collected data from consenting patients. These data were categorized into five areas: demographics, psychiatric conditions, forensic background, clinical treatment history, and social service use. Psychiatric conditions were classified according to the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10). The forensic background included a history of admission to a correctional facility, the type of crime necessitating treatment under the MTSA, and the type of victim involved.

The analysis utilized the following data: outpatient pathway, history of outpatient and inpatient psychiatric treatment, diagnoses of F2 (schizophrenia, schizotypal, and delusional disorders) and F3 (mood [affective] disorders), type of crime, type of victim, and suicidal behavior. Outpatient pathways were distinguished as follows: patients who began outpatient treatment via a direct outpatient order were classified as “direct outpatients,” and those who transitioned to outpatient care following an inpatient order were classified as “indirect outpatients” [2]. Suicidal behavior, outpatient and inpatient histories, and diagnoses of F2 and F3 were recorded as binary variables (yes/no). Crime types were divided into five categories: injury, robbery, sexual assault, arson, and homicide, as covered by the MTSA. Victims were categorized into three types: “familiar” (family members and friends), “strangers” (individuals not known to the patient), and “others” (incidents involving damage to non-human property).

2-3. Statistical analysis

Initially, descriptive statistics were calculated for each variable. Subsequently, a generalized linear model (GLM) was employed to examine the relationship between suicidal behavior and the following variables: outpatient pathway, outpatient history, inpatient history, diagnosis of F2/F3, crime type, and victim type. In this model, suicidal behavior was designated as the outcome variable, with the other variables acting as explanatory factors. Sex and age were included as covariates to adjust their effects.

Odds ratios (ORs) and 95% confidence intervals (CIs) for suicidal behavior were calculated. The significance level was set at 5%. Statistical analyses were performed using IBM SPSS for Windows, version 29.0 (IBM Japan, Ltd., Japan). 　

3-1. Demographic profiles

Table 1 displays the demographic profiles of the forensic patients included in this study. Data from 2,263 patients (73.4% male, 26.6% female) were analyzed. The average age was 44.88 years (SD = 13.12). Suicidal behaviors were observed in 157 patients (6.9%), with 33 cases (1.5%) resulting in completed suicides.

Table 1. Demographics of the Forensic Outpatients (n = 2,263).
Variable		n (%) or mean (SD)
Sex
	Men	1,660 (73.4)
	Women	603 (26.6)
Age (years)		44.88 (13.12)
Outpatient Pathway (direct/indirect)		606/1,657
Outpatient History (yes)		1,794 (79.3)
Inpatient History (yes)		1,296 (57.3)
Psychiatric Diagnoses	F2	1,754 (77.5)
	F3	209 (9.2)
Type of Crime
	Injury	781 (34.5)
	Robbery	104 (4.6)
	Sexual assault	109 (4.8)
	Arson	596 (26.3)
	Homicide	673 (29.7)
Type of Victim
	Familiar	1,060 (46.8)
	Stranger	1,013 (44.8)
	Other	190 (8.4)
Suicidal Behavior (yes)		157 (6.9)
Completed Suicide (yes)		33 (1.5)

3-2. Relationship between suicidal behavior and each variable

Table 2 presents the results of the GLM analysis. Variables associated with increased ORs included being a direct outpatient (OR = 1.63, 95% CI: 1.14–2.34, p = .007), having a history of outpatient treatment (OR = 1.92, 95% CI: 1.07–3.48, p = .030), and being arrested for arson (OR = 2.24, 95% CI: 1.33–3.76, p = .002). A diagnosis of F2 was associated with a decreased risk of suicidal behavior (OR = 0.61, 95% CI: 0.39–0.95, p = .031).

Table 2. Factors Influencing Suicidal Behavior.
Variable	OR	95%CI	p
Outpatient Pathway (ref. indirect)
Direct	1.63	1.14-2.34	.007
Outpatient History (ref. no history)
Yes	1.92	1.07-3.48	.030
Inpatient History (ref. no history)
Yes	1.47	0.98-2.21	.060
F2 (ref. without F2)
Yes	0.61	0.39-0.95	.031
F3 (ref. without F3)
Yes	1.10	0.59-2.04	.774
Type of Crime (ref. injury)
Robbery	1.19	0.48-2.95	.712
Sexual assault	1.93	0.88-4.24	.101
Arson	2.24	1.33-3.76	.002
Homicide	1.61	0.96-2.68	.068
Type of Victim (ref. familiar)
Stranger	0.95	0.61-1.48	.813
Other	0.89	0.48-1.64	.706

This study is the first to identify risk factors associated with suicidal behavior among Japanese forensic patients, utilizing nearly all available data from individuals under the MTSA in Japan. The rate of suicidal behavior among Japanese forensic outpatients was 6.9%, with completed suicides occurring in 1.5% of cases. Our findings revealed significant associations between suicidal behavior and direct outpatient treatment, a history of outpatient psychiatric care, a diagnosis of schizophrenia, and an arrest for arson.

4-1. Suicide among forensic outpatients

The suicide rate in the general population of Japan is estimated at approximately 0.02% [16]. In this study, the rate of completed suicides among forensic outpatients was 1.5%, indicating a significantly higher suicide risk in this group compared to the general population. As previously noted, forensic patients are at an elevated risk for suicide [5-7], a trend that is consistent among Japanese patients. Additionally, compared to the 0.1% rate of completed suicide among general psychiatric outpatients in Japan [17], forensic patients face a substantially higher risk. Furthermore, while the rate of suicidal behavior in the general population is estimated at 2.4% [18], this suggests an even greater risk of suicide attempts among forensic patients. These findings underscore the importance of intensive suicide prevention measures for Japanese forensic patients.

The heightened risk of suicide among forensic patients may arise from the inherently isolating conditions of their environments and the stigma associated with having committed a crime, which complicates their reintegration into society. Forensic patients often experience significant social isolation [19, 20], which is a known risk factor for suicide [21, 22]. Additionally, the stigma they face can adversely affect their mental health [23], potentially leading to suicidal behaviors. Therefore, future efforts in suicide prevention for forensic patients should focus on enhancing their social connections, including relationships with family and friends, and combating stigma against them.

4-2. Suicide and outpatient/inpatient history

This study found that the risk of suicide was higher among forensic patients who had received outpatient treatment in psychiatric clinics before committing criminal acts. However, this increased risk was not observed in patients with a history of inpatient treatment. Additionally, those treated directly as outpatients had a greater risk of suicide than those who were first treated as inpatients and then transitioned to outpatient treatment under the MTSA.

Psychiatric patients often have poor insight into their illness [24-26], which frequently results in medication non-adherence [27-29]. Inpatient treatment is believed to help maintain medication adherence, whereas direct outpatients may lack an understanding of the necessity of medication.

Moreover, patients need social support during psychological crises. Inpatients can build relationships with their medical staff, but social connections are often weak among forensic patients [19, 20]. Consequently, direct outpatients may be isolated, making it challenging to intervene when their conditions worsen. In general, poor adherence, including interruption of medication, increases the risk of suicide [30, 31]. Therefore, maintaining medication adherence and managing symptoms through enhanced support from their families and communities are crucial for forensic outpatients.

4-3. Suicide and schizophrenia

Previous studies have shown higher rates of suicide among patients with schizophrenia [32-34]. The risk of suicide has also been found to be higher among forensic patients with schizophrenia [35]. Therefore, the results of this study, which did not reveal a greater risk of suicide among forensic patients with schizophrenia, are inconsistent with previous findings.

One possible explanation for this inconsistency is the focused interventions implemented in Japan. Japan established a system for the treatment of forensic patients in 2005, more than 30 years later than in Western countries. When establishing the MTSA system, findings from foreign countries were utilized to design interventions specifically for patients with psychiatric disorders [36]. Given the known high rates of relapse [37-39] and suicide [32-34] among patients with schizophrenia, intensive care has been provided for forensic patients with psychosis under the MTSA. It is plausible that these intensive treatment efforts have been successful in preventing suicidal behavior among forensic patients with schizophrenia.

4-4. Suicide and arson

It is known that some arsonists have suicidal tendencies [40-42], and similar findings were observed in this study. Some arsonists are categorized as “suicidal” arsonists [43, 44]. It is estimated that approximately 18% of fire-related deaths in Japan are due to suicide [45], suggesting that some individuals may have committed arson with the intention of committing suicide. Therefore, the risk of suicide should always be considered when evaluating arsonists.

4-5. Limitations

This study identified risk factors for suicidal behavior, including suicide attempts, to facilitate early intervention for Japanese forensic patients. However, risk factors may differ between completed and attempted suicides, necessitating a comparison between them. Additionally, since attempted suicides in this study were based on self-reports, any suicidal behaviors not reported to medical staff were excluded.

Nonetheless, we have demonstrated that the risk of suicide is high among forensic outpatients and identified specific risk factors for suicide. Based on these findings, both a population-based approach for all forensic outpatients and a targeted high-risk approach for patients with identified risk factors for suicide should be implemented under the MTSA system.

This study analyzed data from nearly all Japanese forensic outpatients to identify risk factors for suicidal behavior during their treatment. Various risk factors for suicidal behavior were identified. Since these risk factors are static and can be identified before treatment, professionals should consider them in their treatment plans. Improving social support and reducing prejudice against forensic patients are necessary. Enhancing social support systems and combating stigma will contribute to more effective suicide prevention among forensic patients.

This study was conducted with the approval of the Bioethics Committee of St. Marianna University School of Medicine (Approval No.4783).

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The authors declare no competing interests.

Suicidal Behavior among Forensic Patients in Japan: Risk Factors and Implications for Treatment

Status:

Version 1

Abstract

1. Introduction

2. Methods

3. Results

4. Discussion

5. Conclusion

Declarations

References

Additional Declarations

Status:

Version 1