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Despite robust evidence demonstrating an association between psychosis and violent outcomes, particularly homicide, it remains uncertain whether there is an association between psychosis and repeat offending. A meta-analysis from 1998 concluded that psychosis was inversely related to re-offending, and, in keeping with this, some violence risk assessment instruments have included major mental illness as a protective factor. However, more recent evidence in larger samples has found that schizophrenia is not protective. A recent study of 79 211 prisoners found associations between psychosis and the number of repeat incarcerations in a dose-response manner. Another study of community offenders found no association between being diagnosed with schizophrenia and repeat violent offending. Recent reviews have been descriptive and not quantitatively synthesized the evidence or explored sources of heterogeneity. Therefore, we have undertaken a systematic review and meta-analysis of the risk of repeat offending in patients with psychotic disorders.

Objective: To undertake a systematic review and meta-analysis on the risk of repeat offending in individuals with psychosis and to assess the effect of potential moderating characteristics on risk estimates. 

Methods: A systematic search was conducted in 6 bibliographic databases from January 1966 to January 2009, supplemented with correspondence with authors. Studies that reported risks of repeat offending in individuals with psychotic disorders (n = 3511) compared with individuals with other psychiatric disorders (n = 5446) and healthy individuals (n = 71 552) were included. Risks of repeat offending were calculated using fixed- and random-effects models to calculate pooled odds ratios (ORs). Subgroup and meta-regression analyses were conducted to examine how risk estimates were affected by various study characteristics including mean sample age, study location, sample size, study period, outcome measure, duration of follow-up, and diagnostic criteria. 

Results: Twenty-seven studies, which included 3511 individuals with psychosis, were identified. Compared with individuals without any psychiatric disorders, there was a significantly increased risk of repeat offending in individuals with psychosis (pooled OR = 1.6, 95% confidence interval [CI] = 1.4–1.8), although this was only based on 4 studies. In contrast, there was no association when individuals with other psychiatric disorders were used as the comparison group (pooled OR = 1.0, 95% CI = 0.7–1.3), although there was substantial heterogeneity. Higher risk estimates were found in female-only samples with psychosis and in studies conducted in the United States. 

Conclusions: The association between psychosis and repeat offending differed depending on the comparison group. Despite this, we found no support for the findings of previous reviews that psychosis is associated with a lower risk of repeat offending.

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Fazel S, Yu R. Schizophr Bull. 2011 Jul;37(4):800-10.