There is a far greater risk of lethal assault during the first episode of psychotic illness compared to later episodes, warn mental health experts.
In the latest Medical Journal of Australia (MJA), Dr Olav Nielssen, psychiatrist at St Vincent's Hospital in Sydney, and his co-authors review homicides committed during psychotic illness in NSW between 1993 and 2002.
Of the 88 subjects, 54 (61 per cent) were in their first episode of psychotic illness and had not received effective treatment.
"People in their first episodes of mental illness should be considered to be at greater risk of committing serious violence than those in subsequent episodes," says Dr Nielssen.
"The first episode of psychotic illness should be treated as a psychiatric emergency, with a lower threshold for initiating involuntary treatment.
The main reasons for lethal assault were frightening delusional beliefs in which the patient believed they were in immediate danger.
In a related MJA editorial, Dr Megan Kalucy, Psychiatrist and Masters student of Public Health at the University of Western Australia, and her colleague, Professor Ross Kalucy, Director of Emergency Mental Health at the Flinders Medical Centre in Adelaide, say assertive intervention in such cases may be easier said than done.
Dr Kalucy says it is obviously unrealistic to expect mental health services to predict and prevent all homicides in the context of psychosis because of their rarity and complexity.
"However this study alerts us to be concerned about the risks of homicide or serious violence in the context of early psychosis, especially where certain symptoms and circumstances are present," says Dr Kalucy.
"Whilst assertive intervention may help to reduce homicide rates, it would require an intensive, multidisciplinary input with an often difficult to access population."
Dr Kalucy recommends health professionals should develop a management plan in consultation with family members for any patients they consider a risk.
"Perceived risk by family members, who are most at risk of homicide, must be taken very seriously and be embedded in the ensuing management plan, which should include direct advice as to how they should respond to actual threat," says Dr Kalucy.