Societies, in order to purge themselves, have always found a solution to isolate their criminals. From banishment in the past, to prison today, an intermediate solution has emerged for decades: internment in psychiatry. This internment has practically imposed itself because societies rightly make a link between mental illness and criminality. People with mental disorders have an increased risk of criminality and more particularly of violent criminality . In Togo, the Psychiatric Hospital of Zébé (HPZ) is the only structure adapted for hospitalization without consent, where the transfer of wandering mentally ill patients, violent mentally ill patients and forensic mentally ill patients takes place. When committed offences, forensic mentally ill patients come to HPZ from all the jurisdictions and prisons of the country. Since its creation in 1904 until today, no study on the forensic mentally ill patients has been made in this structure. Thus, it is important to do this study which aimed to describe the socio-demographic, clinical and forensic aspects of the forensic mentally ill patients interned at the HPZ.
2. Framework and Method
Our study took place at the Zébé Psychiatric Hospital (HPZ). The first infrastructures of the HPZ date back to the German colonial period (1904); but it was on May 8, 1931 that the decree creating the hospital was signed, called at the time “Special hospital for indigenous patients with psychopathy”. It is the only closed psychiatric center of reference in Togo. It is located in the South-East of Togo in Aného (Lakes prefecture), about 50 km from the capital Lomé. It has a capacity of 170 beds and is organized into Psychiatric Emergency Unit, Unit for Difficult Patients, Addictology Unit, General Psychiatry Unit and Care and Reintegration Unit.
2.2.1. Type and Period of Study
This was a descriptive cross-sectional study conducted from August 16 to September 16, 2021.
2.2.2. Study Population
The study population consisted of forensic mentally ill patients of all ages and sexes who were admitted to the HPZ during the study period. A forensic mentally ill patient is any person who has committed a crime or misdemeanour and whose psychiatric expertise has found that a mental illness affecting his or her discernment is the cause of the act committed or any person transferred from prison for serious mental illness. The sampling was exhaustive. Forensic mentally ill patients discharged before the study period was not included in this study.
2.2.3. Data Collection
Data were collected using a pre-established survey form with three main items:
· socio-demographic item (nationality, origin, age, sex, level of education, marital status and occupation),
· clinical item (lifestyle, psychiatric history, diagnosis, duration of illness before the forensic offence, duration of psychiatric detention and abandonment of the family),
· and criminological item (forensic offences, identity of the victim, sex of the victim, length of imprisonment, judicial protection measure, conclusion of psychiatric expertise and judicial decision).
Our diagnosis reference was the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) .
2.2.4. Data Analysis
Data were entered and processed using Microsoft Excel 2016 software.
2.2.5. Ethical Considerations
Ethical approval was obtained from the direction of Zébé Psychiatric Hospital. A verbal, free and informed consent was requested from the patients. Confidentiality and anonymity were strictly respected.
3.1. Socio-Demographic Aspects
During the study period, we recorded 28 forensic mentally ill patients out of 214 patients hospitalized at the HPZ (i.e. 13.1%). They were Togolese in 96.4% of cases and from rural areas in 57.1% of cases (Table 1). The mean age of these patients was 37.3, and ranged from 13 to 82 years. The age range of 31 to 40 years represented 39.3% of the patients (Table 1). The male sex represented 96.4% of the patients (i.e. a sex ratio of 27). Primary education represented 39.3% of the cases (Table 1). Single people represented 92.9% of the cases (Table 1). They were unemployed in 64.3% of cases (Table 1).
3.2. Clinical and Forensic Aspects
Forty-six point four percent (46.4%) of the patients in our study were using at least one psychoactive substance (alcohol, tobacco and cannabis were used respectively by 28.6%, 25.0% and 21.4% of the patients) (Table 2). In terms of history, 82.1% of patients had no personal previous psychiatric history and 92.9% of patients had no family previous psychiatric history (Table 2). Forensic offenses were dominated by murder in 53.6% of cases (Table 2). The victim was a
Table 1. Distribution of patients according to socio-demographic data.
family member in 53.6% of cases and male in 60.7% of cases (Table 2). The mean duration of imprisonment before transfer to HPZ was 17.1 months, and ranged from 0 days to 8 years. Schizophrenia spectrum disorders accounted for 78.6% of patients (Table 2). The mean duration of illness before the forensic offense was 6.1 years, and ranged from 4 months to 25 years. No forensic mentally ill patient had been granted legal protection such as a court order, guardianship or curatorship. Forty-six point four percent (46.4%) of the patients were not responsible for their offences and 53.6% were transferred to the HPZ when their condition worsened in prison. The average duration of internment at the HPZ
Table 2. Distribution of patients according to clinical and criminological data.
*Association of several parameters possible.
was 3.4 years, and ranged from 3 months to 12 years. Eighty-two point one percent (82.1%) of these patients were abandoned by their families (Table 2).
4.1. Socio-Demographic Aspects
Young adults situated in majority in the age range of 31 to 40 years (39.3%) predominated among the forensic mentally ill patients of the HPZ. Their mean age was 37.3 years. This predominance of young adults among the forensic mentally ill patients is found by several authors  - . When violence is destructive, it is often the prerogative of an aggressor who is stronger than the victim. It’s why young adults, who are often stronger than vulnerable people (children and the elderly), are over-represented among the forensic mentally ill patients. Almost all of our sample (96.4%) was male, as it has been noted in the literature    . Men, because of their physical strength, tended to commit more violent crimes than women when they are ill. More than two thirds of the forensic mentally ill patients in our sample had a low level of education (primary education 39.3%; no schooling 28.6%). This result is also found by some authors   . This low level of education of forensic mentally ill patients could be due to the fact that less educated people have a tendency to solve their problems by violence. Nevertheless, contrary to our study, Charf N. et al. in Tunisia , in their study on the criminal psychiatric expertise of patients suffering from mood disorders, had noted a good level of education of their study population, namely 39.4% for the secondary level and 13.2% for the higher level. Almost all the patients in our study were single (92.9%). The data in the literature are in the same direction. Indeed, Houidi A. & Paruk S.  in a study similar to ours, in KwaZulu Natal (South Africa), found 97.8% of singles. Bram Khemiri N. et al.  in their study on schizophrenia and intrafamilial crimes in Tunisia, had noted 72.5% of singles. Similarly, Bouhlel S. et al.  in Tunisia had found in their study 88.8% of singles among patients suffering from schizophrenia and who had committed a murder. This implies that these people have always suffered from mental illness, which has prevented them from forming a couple. We can add that this single life could have increased their frustration to the point of committing crimes in their environment. The patients in our study were unemployed in 64.3% of cases. Houidi A. & Paruk S.  had found a higher rate (97.8%). Hattab N. & Asri F.  in Marrakech, Morocco in a similar study and Charfi N et al.  had noticed that the majority of their study population (respectively in 81.81% and 73.7% of cases) had a low standard of living. In our African context where 60% of the unemployed are young , it is obvious that the majority of forensic mentally ill patients who are mostly young adults are in this category of unemployed. The forensic mentally ill patients came from rural areas in 57.1% of the cases. In Hattab N. & Asri F.  study, 63.63% were from rural origin. On the other hand, in Charfi N. et al.  study, 50% came from urban areas and 21.1% from semi-urban areas. In rural areas in sub-Saharan Africa, people are still very attached to cultural practices which require that the mentally ill patient be managed in the family away from the gaze of others. This culture also favors settling disputes amicably within the family rather than going to court. Unfortunately, this sometimes degenerates into macabre scenes.
4.2. Clinical and Forensic Aspects
The majority of patients in our study had neither a personal previous psychiatric history (82.1%) nor a family psychiatric history (92.9%). In Charfi N. et al.  study, personal previous psychiatric history was about 78.9%. For Houidi A. & Paruk S. , the personal previous psychiatric history was about 43.96%. In Hattab N. & Asri F.  study, 32.72% had a family psychiatric history. As for life style habits, almost half (46.4%) of the patients in our study were using at least one psychoactive substance. Alcohol, tobacco and cannabis were consumed respectively by 28.6%, 25.0% and 21.4% of the forensic patients. Our proportion is higher than that of Charfi N. et al.  (31.6% of psychoactive substance use) and lower than that of Hattab N. & Asri F.  who found 66.45% of substance abuse history of which tobacco and cannabis were the most consumed (100% and 50% respectively).
The forensic offenses were, in more than half of the cases, murder (53.6%); the victim was a family member in 53.6% of the cases and male in 60.7% of the cases. In our environment, many patients suffering from schizophrenia in particular are still hidden at home, with their family as their only contact. This explains the predominance of family members among the victims. As for the predominance of men among the victims, it must be said that in rural areas, land and inheritance disputes often pit men against each other. Around these men, a mentally ill person can develop and maintain a persecution delusion, which can lead to physical aggression or even murder. In the series by Hattab N. & Asri F. , Houidi A. & Paruk S.  and Charfi N. et al. , murder represented respectively 54.54%, 14.29% and 10.6% of cases. The majority of patients in our study suffered from schizophrenia spectrum disorders (78.6%). Schizophrenias are considered statistically as the most criminogenic mental illnesses . The literature has already raised the fact that most of the family crimes or crimes on known victims are the work of patients with schizophrenia    . In the same sense, Hattab N. & Asri F.  had noted 85.44% of people with schizophrenia in their study. For Houidi A. & Paruk S. , intellectual disability predominated in 36.26% of cases. Forty-six point four percent (46.4%) of the patients were criminally qualified as not responsible for their offences because they were considered after psychiatric expertise that they were suffering from a mental disorder having abolished their discernment and the control of their acts at the time of the facts. On the other hand, 53.6% of these patients had been transferred to the HPZ due to the aggravation of their psychiatric condition in prison. No psychiatric care structure exists in Togo’s prisons, hence the reference to the HPZ. The scarcity of psychiatrists in Togo (five psychiatrists for approximately 7,000,000 inhabitants) means that not all criminals have the chance to have a psychiatric expertise in time. For fear of further crimes, almost all forensic patients (82.1%) were abandoned by their families. Even when they were stabilized, they continued to reside at the HPZ (the average duration of internment at the HPZ was 3.4 years, and ranged from 3 months to 12 years).
4.3. Limitation of the Study
Although our sample was exhaustive, we had very few forensic mentally ill patients to study. This small sample of forensic mentally ill patients is a limitation of our study. However, our results are valid because they represent the totality of the forensic mentally ill patients of the only one reference structure in Togo, adapted for hospitalization without consent, where this type of patient transits.
The HPZ is the only psychiatric hospital in Togo able to accommodate forensic mentally ill patients who make up 13.1% of the total population of this hospital. These forensic patients are often young adults, single, unemployed and with a low level of education. More than half of them have committed a murder against a male family member. Schizophrenia spectrum disorders are the most common pathology among them. The information gathered in this study will help to better organize strategies for mental health promotion and prevention of mental illness and crime in the general population.
INVESTIGATION SHEET NO: ..............
1) SOCIO-DEMOGRAPHIC ITEM
Nationality: ………… Provenance: Urban Rural Gender: Male Female Age: ……... Education: No schooling Primary Secondary University
Marital status: Single Married Divorced Widowed
Profession: Craftsmen/Cultivators Officials Unemployed Others: ……………
2) CLINICAL ITEM
Lifestyle habits: Alcohol: Yes No Tobacco: Yes No Cannabis: Yes No
Tramadol: Yes No Cocaine: Yes No
Personal psychiatric history: Yes No Family psychiatric history: Yes No
Psychiatric diagnosis (DSM5): ......................................................................
Duration of disease progression before the forensic infraction: ...................
Duration of psychiatric internment: ....................................................................
Family abandonment: Yes No
3) CRIMINOLOGICAL ITEM
Forensic offence: Murder: Yes No Assault: Yes No Others: …
Identity of the victim: Family member Yes No Stranger: Yes No
Sex of the victim: Male Female Duration of imprisonment:.................
Judicial protection measure: Safeguard of justice: Yes No Tutorship: Yes No Curatorship: Yes No
Psychiatric expertise: Yes No
Conclusion of the psychiatric expertise: ..................................................
Court decision: .............................................................................
 Charfi, N., Omri, S. and Zouari, L. (2016) Expertise psychiatrique pénale des malades atteints de troubles de l’humeur: à propos d’une expérience tunisienne. La revue de médecine légale, 7, 97-104.
 Houidi, A. and Paruk, S. (2018) Profile of Forensic State Patients at a Psychiatric Unit in KwaZulu Natal, South Africa: Demographic, Clinical and Forensic Factors. The Journal of Forensic Psychiatry & Psychology, 29, 1-13.
 Bram Khemiri, N., Ghazali, I. and Ridha, R. (2012) Schizophrénie et crimes intrafamiliaux. étudeanalytique et comparative à propos de 80 cas. L’Information psychiatrique; 88, 839-846.
 Bram Khemiri, N., Ben Ameur, R.R., Ben Romdhane, I. and Ridha, R. (2013) Trouble bipolaire et criminalité en Tunisie: étude comparative en fonction du sexe. L’Information psychiatrique, 89, 735-742.
 Bouhlel, S., Nakhli, J., Ben Meriemb, H., Ridha, R. and Ben Hadj Ali, B. (2013) Les facteurs liés aux actes d’homicide chez les patients tunisiens atteints de schizophrénie. L’évolution psychiatrique, 79, 611-618.
 Richard-Devantoy, S., Duflot, J.P., Chocard, A.S., Lhuillier, J.P., Garre, J.B. and Senon, J.L. (2009) Homicide et schizophrénie: à propos de 14 cas de schizophrénie issus d’une série de 210 dossiers d’expertises psychiatriques pénales pour homicide. Annales Médico-Psychologiques, 167, 616-624.