Lindbe g e al.
Child Adolesc Psychia y Men Heal h (2017) 11:37
DOI 10.1186/s13034-017-0174-3
RESEARCH ARTICLE
Mo ali y o young o ende s: a
na ional egis e -based ollow-up s udy
o 15- o19-yea -old Finnish delinquen s
e e ed o  o ensic psychia ic examina ion
be ween1980 and2010
Nina Lindbe g1*, Jouko Mie unen2,3, Anni Heiskala2 and Rii ake u Kal iala‑Heino4,5,6
Abs ac
Backg ound: The mo ali y a e o young o ende s is high. Fu he mo e, mo ali y in young o ende s is associa ed
wi h psychia ic and subs ance use diso de s. The p ima y aim o his na ional egis e ‑based ollow‑up s udy was o
in es iga e he mo ali y a e o Finnish delinquen s who unde wen a o ensic psychia ic examina ion be ween 1980
and 2010. As delinquency is no a solid en i y, we u he aimed o compa e he isk o p ema u e dea h among di ‑
e en subg oups o he delinquen s; iolen e sus non‑ iolen o ende s, o ende s wi h alcohol use diso de s e sus
hose wi h no such diagnoses, o ende s wi h schizoph enia spec um diso de s e sus conduc ‑ and pe sonali y‑
diso de ed o ende s, unde ‑aged e sus young adul o ende s, and, inally, boys e sus gi ls.
Me hods: We collec ed he o ensic psychia ic examina ion epo s o all 15‑ o 19‑yea ‑old o ende s who we e
bo n in Finland and had unde gone he examina ion be ween 1.1.1980 and 31.12.2010 (n = 606) om he a chi es o
he Na ional Ins i u e o Heal h and Wel a e and e ospec i ely e iewed hem. Fo each delinquen , ou age‑, gen‑
de ‑ and place o bi h‑ma ched con ols we e andomly selec ed om he Cen al Popula ion Regis e (n = 2424).
The delinquen s and hei con ols we e ollowed un il he end o 2015. The median ollow‑up ime was 23.9 yea s
(in e qua ile ange 15.3–29.5). We ob ained he mo ali y da a om he causes o dea h egis e . Dea hs a ibu able
o a disease o an occupa ional disease we e conside ed na u al, and hose a ibu able o an acciden , suicide o
homicide we e conside ed unna u al.
Resul s: By he end o he ollow‑up pe iod, 22.1% (n = 134) o he delinquen s and 3.4% (n = 82) o hei con ols
had died (OR 8.11, 95% CI 6.05–10.86, p < 0.001). Among boys, 22.0% (n = 121) o he delinquen s and 3.7% (n = 81)
o he con ols had died (OR 7.38, 95% CI 5.46–9.95, p < 0.001). Male delinquen s’ isk o unna u al dea h was almos
11‑ old, o na u al dea h mo e han wo old, and o unclea dea h mo e han ou old compa ed o ha o hei
con ols. No gi ls had na u al o unclea dea hs, bu 23.6% (n = 13) o he delinquen s and 0.5% (n = 1) o he con ols
had died due o unna u al causes (OR 67.79, 95% CI 8.63–532.00, p < 0.001). The iolen delinquen s’ isk o p ema u e
dea h was wice ha o he non‑ iolen delinquen s. The o he compa isons demons a ed no s a is ically signi ican
di e ences be ween subg oups.
Conclusions: E en hough he Finnish co ec ion sys em p e e s psychia ic ea men and ehabili a ion o e c imi‑
nal sanc ions, and he na ional heal h ca e sys em o e s de elopmen al‑phase‑speci ic psychia ic ca e, he mo ali y
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Open Access
Child and Adolescen Psychia y
and Men al Heal h
*Co espondence: nina.lindbe g@hus. i
1 Fo ensic Psychia y, Helsinki Uni e si y and Helsinki Uni e si y Hospi al,
PO Box 590, 00029 HUS Helsinki, Finland
Full lis o au ho in o ma ion is a ailable a he end o he a icle
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Lindbe g e al. Child Adolesc Psychia y Men Heal h (2017) 11:37
Backg ound
The p ema u e mo ali y o young o ende s is high. Fo
example, a ollow-up s udy by Co ey e al. [1] epo ed
an o e all s anda dized mo ali y a io (SMR) o 9.4 [95%
con idence in e al (CI) 7.4–11.9] o male and 41.3
(95% CI 20.2–84.7) o emale delinquen s aged 10–20.
The link be ween c iminal beha io and excess p ema-
u e mo ali y emains h oughou li e: a me a-analysis
by Zlod e and Fazel [2] showed SMR anges be ween
1.0 and 9.4 o men and be ween 2.6 and 41.3 o women
ollowing elease om p ison. P ema u e dea h is o en
a ibu able o acciden s, suicides, homicides [3–5],
in ec ions [4], and subs ance abuse [4], and is commonly
associa ed wi h iolence [3–5]. Acco ding o a 50-yea
ollow-up s udy by Laub and Vaillan [4], along wi h
aging, he a o emen ioned causes o dea h a e accompa-
nied by medical condi ions and diseases such as cance s
and ca dio ascula diseases. The mo ali y a e a ies
depending on he se e i y o jus ice sys em in ol emen :
a es ed you h has he lowes a e o mo ali y, ollowed
by de ained and inca ce a ed you h [6]. Mo eo e , high
delinquency se e i y shows ea lie and highe mo ali y
isk [7].
Ju enile delinquency is s ongly linked o psychia ic
mo bidi y. Be ween abou hal and wo hi ds o young
o ende s mee he diagnos ic c i e ia o a conduc dis-
o de , and be ween abou a hi d and a hal o a sub-
s ance-use diso de [8–10]. Mo eo e , bo h bo de line
[11, 12] and an isocial [13] pe sonali y diso de s associ-
a e highly wi h c iminali y. Findings on he p e alence
o psychoses seem con adic o y, bu acco ding o a
me a-analysis o 25 su eys ocusing on de ained ado-
lescen s, i seems o be abou h ee pe cen [10]. People
wi h men al heal h diso de s show excessi e mo ali y
[14]. Se e e conduc -diso de ed beha io is associa ed
wi h an inc eased isk o p ema u e dea h, mos ly due o
acciden s, suicide and homicide [15]. Recen ly, a commu-
ni y-based ollow-up s udy highligh ed he associa ion
be ween adolescen conduc p oblems and p ema u e
dea h a ibu able o ca dio ascula diseases and cance s
[16]. Bo h bo de line and an isocial pe sonali y diso de s
ela e s ongly o impulsi e and sel -dis up i e beha io
[17–20], leading o an ele a ed isk o unna u al dea h.
An isocial pe sonali y diso de is o en linked o Clon-
inge ’s ype 2 alcoholism [21] leading o high mo ali y
om alcohol- ela ed diso de s [22]. Acco ding o a s udy
by Hoye e al. [23], men wi h pe sonali y diso de s also
su e highe mo ali y due o soma ic diso de s o he
han hose ela ed o alcohol han he gene al popula ion,
mos p obably due o unde epo ing o soma ic symp-
oms and less help-seeking. Wi h ega d o people wi h
schizoph enia spec um diso de s, coho s udies ha e
e ealed ha he mo ali y a e o diseases and medical
condi ions is mo e han double han ha o he gene al
popula ion [24, 25]. Among delinquen s, hospi aliza ion
o a psychia ic diso de o subs ance abuse associa es
signi ican ly wi h he isk o p ema u e dea h [3].
The numbe o ju enile p isone s in Finland has a-
di ionally been low by in e na ional s anda ds because
o he widesp ead use o condi ional p ison sen ences
and special you h punishmen s, including social eha-
bili a ion and occupa ional ac i i ies [26]. Unde -aged
delinquen s wi h se e e o ending a e ypically e e ed
o child-wel a e ins i u ions, which ocus on ehabili a-
ion a he han co ec ion. Fo example, he e we e only
11 unde -aged indi iduals in Finnish p isons in 2015,
(C iminal Sanc ions Agency, pe sonal communica ion).
Fu he , acco ding o Finnish law, cou s can send an
indi idual o a p e ial o ensic psychia ic examina ion
o de e mine whe he he/she is su e ing om a men-
al diso de ha migh a ec his/he c iminal esponsi-
bili y. The inal o ensic psychia ic epo includes an
opinion on he o ende ’s le el o c iminal esponsibili y,
as well as possible psychia ic diagnoses and an assess-
men as o whe he o no he o ende ul ils he c i e ia
o in olun a y psychia ic ca e. Fo example, o end-
e s wi h schizoph enia spec um diso de s a e ypically
e e ed o in olun a y psychia ic ea men . Finland
was he i s coun y in Eu ope o acknowledge adoles-
cen psychia y as an independen special y in he ield
o medicine wi h i s own se ice egime: I was a dis inc
subspecial y in psychia y be ween 1979 and 1994, un il
i became an independen medical special y. Since hen,
bo h educa ion and esea ch on adolescen men al heal h
diso de s and hei ea men ha e gained s eng h in
Finland.
In his na ional egis e -based ollow-up s udy, we col-
lec ed a consecu i e sample o Finnish delinquen s who
we e sen o a p e ial o ensic psychia ic examina ion
be ween 1980 and 2010, and ollowed hem un il he end
o 2015. Ou p ima y aim was o in es iga e hei mo -
ali y a e. We assumed ha due o he abo e-men ioned
a e o delinquen s, especially o hose wi h a his o y o iolen o ences, is high. The excess mo ali y o o ende s can
be ega ded as a speci ic public‑heal h inequi y ha calls o mo e e ec i e in e en ion p ocedu es han hose used
hus a .
Keywo ds: Dea h, Delinquency, Mo ali y, O ending, Psychopa hology
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Lindbe g e al. Child Adolesc Psychia y Men Heal h (2017) 11:37
special ea u es ela ed o Finnish judicial p ac ices and
men al heal h sys em, we would obse e lowe mo ali y
a es han hose epo ed by Co ey e al. [1]. Secondly, as
delinquency is no a solid en i y, we wan ed o compa e
he isk o p ema u e dea h among di e en subg oups o
delinquen s; iolen e sus non- iolen o ende s, o end-
e s wi h alcohol use diso de s e sus hose wi h no such
diagnoses, o ende s wi h schizoph enia spec um diso -
de s e sus conduc - and pe sonali y-diso de ed o end-
e s, unde -aged e sus young adul o ende s, and inally,
boys e sus gi ls. On he basis o ea lie esea ch indings,
we hypo hesized ha delinquen s wi h iolen o end-
ing would show signi ican ly highe p ema u e mo ali y
han hose wi h non- iolen o ending, and ha delin-
quen s wi h ea ly onse alcohol abuse/dependence would
ha e a signi ican ly highe p ema u e mo ali y a e han
hose wi hou hese diso de s. We also assumed ha , as
delinquen s wi h schizoph enia spec um diso de s a e
e e ed o in olun a y psychia ic inpa ien ca e, hei
mo ali y a e would be signi ican ly lowe han ha o
delinquen s wi h conduc and pe sonali y diso de s. We
u he assumed ha , as unde -aged delinquen s wi h
se e e o ending a e e e ed o child-wel a e ins i u ions,
hei mo ali y a e would be signi ican ly lowe han ha
o hei adul coun e pa s. The p ema u e mo ali y a e
o Finnish males is known o be app oxima ely wice ha
o emales [27]. We hypo hesized ha we would obse e
he same kind o gende di e ence in ou o ende
popula ion.
Sample andme hods
Sample andp ocedu e
The minimum age o c iminal liabili y in Finland is
15 yea s. The Na ional Ins i u e o Heal h and Wel-
a e o ganizes o ensic psychia ic examina ions. These
examina ions a e inpa ien e alua ions ha las app oxi-
ma ely 2mon hs, and include da a ga he ed om a i-
ous sou ces ( he ju enile him/he sel , amily membe s,
ela i es; and medical, c iminal, school, child-wel a e and
mili a y eco ds), psychia ic e alua ions, s anda dized
psychological es s, in e iews conduc ed by a mul i-
p o essional eam, an e alua ion o he o ende ’s physi-
cal condi ion, and con inuous obse a ion by he hospi al
s a . The o e all high quali y and eliabili y o Finnish
o ensic psychia ic examina ions a e acknowledged in
he cou s and among scien is s [28]. The In e na ional
Classi ica ion o Diseases—Eigh h e ision (ICD-8)
[29] was used o he pu poses o psychia ic classi ica-
ion in Finnish clinical p ac ice be ween 1968 and 1986.
I was eplaced by he Diagnos ic and S a is ical Manual
o Men al Diso de s—Thi d e ised edi ion (DSM-III-R)
[30] which was used be ween 1987 and 1995. Howe e ,
he diagnoses we e con e ed in o ICD-9 [31] diagnoses,
e.g. when epo ing hem o he ca e egis e o heal h
ca e. The ICD-10 [32] has been used since 1996.
We collec ed psychia ic examina ion epo s on all
15- o 19-yea -old o ende s who we e bo n in Finland
and unde wen he examina ion be ween 1.1.1980 and
31.12.2010 om he a chi es o he Na ional Ins i u e
o Heal h and Wel a e. The E hics Commi ee o Hel-
sinki Uni e si y Hospi al and he pe inen ins i u ional
au ho i ies app o ed he s udy p o ocol.
Pa icipan s
The s udy pa icipan s comp ised 606 delinquen s (gi ls:
9.1%; n=55) o Finnish o igin. The c iminal his o ies o
he delinquen s we e e iewed, and, in line wi h Fazel
and G ann [33], mu de , a emp ed mu de , manslaugh-
e , a emp ed manslaugh e , a son, agg a a ed assaul ,
assaul , obbe y, kidnapping, ape, a emp ed ape, and
child moles a ion we e all ega ded as iolen o ences;
and he , bu gla y, d i ing while in oxica ed, dange -
ous d i ing, d i ing wi hou a d i ing license, as well as
d ug smuggling and selling d ugs we e ega ded as non-
iolen o ences. I he pe son had commi ed mo e han
one o ence, we ook he mos se e e one. O all delin-
quen s, 83.5% (n=506) had o ended iolen ly and 16.5%
(n=100) non- iolen ly. Fu he , 42.7% (n=259) o he
delinquen s had commi ed hei index o ence as mino s.
Acco ding o he p incipal psychia ic diagnoses gi en
in he o ensic psychia ic examina ion, 1.3% (n=8) o
he delinquen s we e men ally disabled (IQ<70), 9.4%
(n = 57) we e diagnosed wi h a schizoph enia- ela ed
diso de , and 79.2% (n=479) had a conduc diso de
o a pe sonali y diso de (mainly an isocial, bo de line
o mixed). Fu he , 7.6% (n=46) o he delinquen s had
some o he psychia ic diso de (mainly dep essi e and
anxie y diso de s) and 2.6% (n=16) o hem showed
no psychia ic diso de . O he 606 delinquen s, 45.4%
(n=275) we e diagnosed wi h como bid alcohol abuse
o dependence.
Con ols
Fo each delinquen , ou con ols we e andomly
selec ed om he Cen al Popula ion Regis e and
ma ched o age, gende and place o bi h. The e we e no
exclusion c i e ia o his gene al popula ion da a.
Follow‑up
The ollow-up pe iod s a ed when he delinquen ’s
o ensic psychia ic examina ion was comple e (= he
index day). The delinquen s and hei con ols we e ol-
lowed un il 31.12.2015. The median ollow-up ime was
23.9yea s (in e qua ile ange=IQR 15.3–29.5).
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Lindbe g e al. Child Adolesc Psychia y Men Heal h (2017) 11:37
Mo ali y
The pe sonal iden i ica ion numbe ha is assigned o all
esiden s o Finland by he Cen al Popula ion Regis e
was used o link he da a wi h S a is ics Finland’s cause
o dea h egis e . Dea h ce i ica es con ain in o ma ion
on he p ima y cause o dea h, which is always epo ed,
and in some cases in o ma ion on seconda y causes. The
class o dea h is epo ed as ollows: a ibu able o a dis-
ease, an occupa ional disease, an acciden , medical ca e,
suicide, homicide, wa , o a eason ha emains unclea .
In his s udy, dea hs a ibu able o a disease o an occu-
pa ional disease we e conside ed na u al, and hose
a ibu able o an acciden , suicide o homicide we e
conside ed unna u al. I was assumed ha no dea hs
a ibu able o a wa would be epo ed in his sample,
gi en ha he Finnish–So ie Con inua ion Wa , which
was he las wa in which Finland was engaged, ended in
he au umn o 1944. All dea h ce i ica es a e e i ied by
a physician a he egional le el, and by medical expe s
a S a is ics Finland. The egis e includes he dea hs o
all ci izens and pe manen esiden s o Finland, as well
as hose o Finnish ci izens ab oad. Du ing he ollow-
up pe iod, 53 people (15 delinquen s and 38 con ols)
mo ed ab oad—mos commonly o o he No dic coun-
ies. They we e included in he analysis on he assump-
ion ha he S a is ics Finland is in o med o dea hs ha
occu ab oad.
S a is ics
We used he likelihood a io Chi squa e- es o com-
pa e he delinquen s and hei gende -, age- and place o
bi h-ma ched con ols. Su i al was analyzed by means
o Kaplan–Meie su i al plo s, and g oup compa isons
we e made using he log ank es : Findings we e consid-
e ed signi ican when wo- ailed p<0.05. The odds a io
(OR) and he haza d a io (HR) wi h 95% CIs we e used
as measu es o he e ec size. R e sion 3.3.1 (h p://
www.R-p ojec .o g) was used o he s a is ical analyses.
Resul s
Table1 p esen s he mo ali y o delinquen s and hei age-,
gende -, and place o bi h-ma ched con ols. Wi h ega d
o ORs, delinquen s’ isk o all-cause mo ali y was mo e
han eigh imes ha o hei con ols. Male delinquen s’
isk o all-cause mo ali y was mo e han se en imes ha
o male con ols. Among gi ls, delinquen s’ isk o all-cause
mo ali y was mo e han 67 imes ha o hei con ols. Fig-
u e1 p esen s he cumula i e su i al o delinquen s and
hei con ols du ing he 36-yea ollow-up pe iod. Figu e2
ocuses on he cumula i e su i al o boys, and Fig.3 on
ha o gi ls. Wi h ega d o di e en classes o dea h, male
delinquen s’ isk o unna u al dea h was almos 11- old,
isk o na u al dea h mo e han wo old, and isk o unclea
dea h mo e han ou old compa ed o ha o male con-
ols. Among gi ls, he e we e no na u al o unclea dea hs,
Table 1 Mo ali y o delinquen s and ha o  hei age-, gende -, andplace o bi h-ma ched con ols du ing he ollow-
up
OR odds a io, CI con idence in e al, Na u al dea hs dea hs a ibu able o a disease o an occupa ional disease, Unna u al dea hs acciden s, suicides, homicides
Delinquen s Con ols OR CI 95% p
n=606 n=2424
All
Dea hs o al; n (%) 134 (22.1) 82 (3.4) 8.11 6.05–10.86 <0.001
Na u al 23 (3.8) 36 (1.5) 2.62 1.54–4.45 <0.001
Unna u al 107 (17.6) 42 (1.7) 12.16 8.40–17.60 <0.001
Unclea 4 (0.7) 4 (0.2) 4.02 1.00–16.12 0.03
n=551 n=2204
Boys
Dea hs o al 121 (22.0) 81 (3.7) 7.38 5.46–9.95 <0.001
Na u al 23 (4.2) 36 (1.6) 2.62 1.54–4.46 <0.001
Unna u al 94 (17.1) 41 (1.9) 10.85 7.42–15.87 <0.001
Unclea 4 (0.7) 4 (0.2) 4.02 1.00–16.13 0.03
n=55 n=220
Gi ls
Dea hs o al 13 (23.6) 1 (0.5) 67.79 8.63–532.00 <0.001
Na u al 0 (0.0) 0 (0.0) – – –
Unna u al 13 (23.6) 1 (0.5) 67.79 8.63–532.00 <0.001
Unclea 0 (0.0) 0 (0.0) – – –
Page 5 o 9
Lindbe g e al. Child Adolesc Psychia y Men Heal h (2017) 11:37
bu he delinquen s’ isk o unna u al dea h was mo e han
67- old compa ed o ha o hei con ols.
O he 94 unna u al dea hs among he male delin-
quen s, 45.7% (n=43) we e classi ied as suicides, 20.2%
(n=19) as homicides, and 34.0% (n=32) as conse-
quences o a ious acciden s. Among he emale delin-
quen s, 69.2% (n=9) o hei 13 dea hs we e a ibu able
o suicide, 15.4% (n=2) o homicide, and 15.4% (n=2)
o an acciden . The causes o he 36 na u al dea hs among
delinquen males included ci hosis o he li e , gas ic
bleeding, pneumonia, ca diac disease, ce eb al hemo -
hage, and malignancies.
Table2 p esen s he compa isons be ween he di e en
subg oups o delinquen s. The di e ences be ween he
Fig. 1 The cumula i e su i al o 606 delinquen s and 2424 con ol
subjec s du ing he 36‑yea ollow‑up pe iod
Fig. 2 The cumula i e su i al o 551 male delinquen s and 2204
con ol subjec s du ing he 36‑yea ollow‑up pe iod
Fig. 3 The cumula i e su i al o 55 emale delinquen s and 220
con ol subjec s du ing he 36‑yea ollow‑up pe iod
Table 2 Compa isons be weendi e en subg oups o 606
delinquen s
HR haza d a io, CI con idence in e al, CD conduc diso de , PD pe sonali y
diso de
Dea hs n (%) HR CI 95% p
Gende
Boys 121/551 (22.0) 0.85 0.48–1.51 NS
Gi ls 13/55 (23.6) Re
Age
Mino s 50/259 (19.3) 0.76 0.54–1.08 NS
Young adul s 84/347 (24.2) Re
C iminal his o y
Violen 121/506 (23.9) 2.01 1.14–3.57 0.009
Non‑ iolen 13/100 (13.0) Re
Diagnosis
Schizoph enia spec um
diso de s 8/57 (14.0) 0.62 0.31–1.28 NS
CD/PD 116/479 (24.2) Re
Como bid alcohol abuse/dependence
Yes 59/275 (21.5) 1.10 0.78–1.55 NS
No 75/331 (22.7) Re

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Lindbe g e al. Child Adolesc Psychia y Men Heal h (2017) 11:37
isk o p ema u e dea h among delinquen s wi h alcohol
use diso de s and hose wi hou hese diso de s, among
delinquen s wi h schizoph enia spec um diso de s and
hose wi h conduc /pe sonali y diso de s, among unde -
aged and young adul o ende s, o among boys and gi ls
we e no s a is ically signi ican . Howe e , when iolen
delinquen s we e compa ed o non- iolen ones, hei
isk o p ema u e dea h was wo old.
Discussion
Ou sample appea s o be highly dis inc om hose p e-
sen ed in ea lie s udies [8–10]: <3% o delinquen s we e
no gi en a psychia ic diagnosis in he o ensic psychi-
a ic examina ion, and psycho ic diso de s we e app oxi-
ma ely h ee imes as common as in a la ge me a-analysis
by Fazel e al. [10]. Ne e heless, as in p e ious delin-
quency s udies [8, 9], conduc and pe sonali y diso de s
u ned ou o be he mos common psychia ic diagnoses.
In line wi h he esul s o ea lie mo ali y s udies [1, 4],
ou delinquen s aced a high mo ali y isk, and he inci-
dence o unna u al causes o dea h was p onounced. The
isk o p ema u e dea h was compa able o ha epo ed
by Co ey e al. [1] and by Zlod e and Fazel [2], bu was
e en highe among emale delinquen s. The numbe o
emale delinquen s was small (<10% o he o al sample),
bu all dea hs among gi ls we e a ibu ed o unna u al
causes.
Delinquen s wi h a his o y o iolen o ending aced
a wo old isk o p ema u e dea h compa ed o delin-
quen s wi h no such his o y. This inding is in line wi h
he esul s o a p e ious ollow-up s udy by T umbe a
e al. [7] among 14- o 15-yea -old nin h g ade s, which
indica ed ha he se e i y o delinquency is ela ed o
he isk o p ema u e dea h. Mo eo e , a ollow-up s udy
among almos 50,000 young men ec ui ed om he
mili a y se ice ound ha iolen o ending is associ-
a ed wi h excess mo ali y and he isk o dying om an
alcohol o d ug- ela ed cause o suicide [34]. The highes
p opo ion o cases o dea h was obse ed among men
who had commi ed a leas one iolen c ime bu we e
also ic ims o iolence hemsel es [34]. In empe amen
s udies, iolen ly beha ing o ende s ha e sco ed high on
no el y-seeking, impulsi eness and i i abili y [35]. These
ai s make hem p one o acciden s, and hei isk o
becoming ic ims o iolence is high, which bo h lead o
an inc eased mo ali y isk [36].
Schizoph enia [37], conduc diso de [15, 16] as well as
an isocial [38] and bo de line [39] pe sonali y diso de s
a e all associa ed wi h excess mo ali y. Con a y o ou
hypo hesis, we we e unable o ind a subs an ial di e -
ence be ween he isk o p ema u e dea h among delin-
quen s diagnosed wi h schizoph enia spec um diso de s
and among hose diagnosed wi h conduc o pe sonali y
diso de s. This inding is in e es ing, gi en ha he Finn-
ish co ec ion sys em singles ou hose who su e om a
psycho ic diso de and e e s hem o psychia ic hospi-
als, whe e he ea men pe iods equen ly las o se -
e al yea s. This was also he case among ou delinquen s
wi h schizoph enia spec um diso de s: hey we e all
e alua ed as lacking c iminal esponsibili y and sen o
in olun a y psychia ic inpa ien ea men . This p oce-
du e did no seem o help in e ms o educing hei p e-
ma u e mo ali y, howe e , when hey we e compa ed o
an isocially beha ing delinquen s who we e no simila ly
ea ed. Indeed, low socioeconomic s a us, un a o able
heal h beha io s such as smoking and d ug and alcohol
abuse, as well as sel -des uc i e beha io s and suicide
endencies a e all linked o o ende popula ions in gen-
e al, ega dless o indi idual psychia ic diagnoses. Some
au ho s ha e iden i ied an ipsycho ic medica ion as a
cause o excess mo ali y [40], bu o he s ha e epo ed
he opposi e inding [41].
An isocial pe sonali y diso de is linked o Cloninge ’s
ype 2 alcoholism, which is cha ac e ized by s ong
physical dependence ha ypically al eady de elops in
adolescence [21]. Almos hal o ou delinquen s we e
diagnosed wi h alcohol abuse o dependence, which mos
p obably mi o s his well-known ela ionship. Con a y
o ou hypo hesis, we obse ed no signi ican di e ence
be ween he all-cause mo ali y o hose who we e diag-
nosed wi h alcohol use diso de s and hose who we e
no . Un o una ely, we had no in o ma ion on o ende s’
la e alcohol use, bu we assume ha many o hose wi h
no alcohol use diso de a he ime o he o ensic psy-
chia ic examina ion migh ha e been diagnosed acco d-
ingly la e in li e, which migh explain ou inding.
The majo i y o Finnish unde -aged delinquen s wi h
se e e o ending a e e e ed o child-wel a e ins i u ions
such as esiden ial schools, which ocus on ehabili a-
ion a he han punishmen . Educa ion, o example,
has a high p io i y in hese ins i u ions. The esiden ial
school placemen ends a he age o 18, when he adoles-
cen s a e o e ed a olun a y 5-yea a e -ca e p og am
[42]. Con a y o ou hypo hesis, he isk o p ema u e
dea h did no signi ican ly di e be ween delinquen s
who had commi ed hei index c imes unde -aged and
hose who had commi ed hem as young adul s (aged 18
o 19). Howe e , many o ou young adul o ende s had
also been clien s o child-wel a e du ing hei childhood
o adolescence; hence we canno d aw any inal conclu-
sions ega ding he ole o child-wel a e in educing la e
mo ali y isk. Howe e , Manninen e  al. [43] ecen ly
epo ed ha Finnish adolescen s placed in esiden ial
schools show a subs an ially ele a ed mo ali y isk in
young adul hood compa ed o ha o he gene al popu-
la ion. The au ho s concluded ha o educe mo ali y,
Page 7 o 9
Lindbe g e al. Child Adolesc Psychia y Men Heal h (2017) 11:37
mo e e ec i e ea men o men al and subs ance-use-
ela ed p oblems du ing and a e he esiden ial school
placemen is needed.
Con a y o ou hypo hesis, he e was no subs an ial
gende di e ence be ween he all-cause mo ali y o male
and emale delinquen s. We ha e p e iously shown ha
when male and emale delinquen s ma ched o age and
ype o c ime a e compa ed o each o he , he emales
esemble hei male coun e pa s in many psychoso-
cial ad e si ies [44]. The p esen esul adds o his wi h
ega d o mo ali y.
S eng hs andlimi a ions
The main s eng h o his s udy lies in i s na ionwide and
comp ehensi e na u e. The Finnish adi ion o ho ough
o ensic psychia ic examina ion and eliable s a is ics con-
s i u e a solid basis o egis e -based s udies. The clea -
ance a e o iolen c imes in Finland is high [45]. The
p opo ion o emales was low, bu co esponds qui e well
o he p opo ion o emales who commi iolen c imes, as
epo ed by na ional s a is ics on police-in es iga ed c ime
and sel - epo ed ju enile delinquency [46]. The es ima e
o emale delinquen s’ mo ali y isk mus be ega ded as
un eliable, as he e was only one dea h among he emale
con ols. In addi ion, some 95% CIs we e qui e la ge. The
median ollow-up pe iod was subs an ial, almos 24yea s.
As in many egis e -based ollow-up s udies, he con ols
we e ma ched acco ding o age, gende and place o bi h,
bu no o socio-economic s a us o auma his o y, bo h
o which a e known o inc ease mo ali y isk [47–49]. I
should also be bo ne in mind ha he cou s decide who
is sen o a p e ial o ensic psychia ic examina ion, and
ha hese decisions could be desc ibed as somewha a bi-
a y. We know ha he majo i y o homicidal adolescen s
unde go his examina ion [50]. Wi h ega d o o he c ime
ypes, an adolescen is ypically sen o an examina ion,
i he cou expec s ha he/she migh be su e ing om a
men al heal h diso de , bu his decision is o en decided
wi hou he bene i o medical expe ise. E en hough we
collec ed delinquen s’ p ima y psychia ic diagnoses as
well as alcohol use diso de diagnoses, we did no assess
he se e i y o psychopa hological symp oms. Ou sample
comp ised only 16 delinquen s wi h no psychia ic diso -
de ; hus, we did no compa e psychia ic and non-psychi-
a ic delinquen s. To shed ligh on his issue, new s udies
wi h su icien ly la ge sample sizes a e needed. All he p e-
ial o ende s we e Finns by o igin, hus he esul s canno
be gene alized o immig an s.
Conclusions
E en hough he Finnish co ec ion sys em p e e s psy-
chia ic ea men and ehabili a ion o e c iminal
sanc ions, and he na ional heal h ca e sys em o e s
de elopmen al-phase-speci ic psychia ic ca e, he mo -
ali y a e o delinquen s, especially o hose wi h a his-
o y o iolen o ending, is high. The excess mo ali y
o o ende s can be ega ded as a speci ic public-heal h
inequi y ha calls o mo e e ec i e in e en ion p oce-
du es han hose used hus a .
Abb e ia ions
CI: con idence in e al; DSM: he Diagnos ic and S a is ical Manual o Men al
Diso de s; HR: haza d a io; ICD: In e na ional Classi ica ion o Diseases; OR:
odds a io.
Au ho s’ con ibu ions
NL collec ed he da a and wo ked as he i s au ho , AH and JM conduc ed
he s a is ical analyses, RK‑H planned he s udy p o ocol wi h NL, and all he
au ho s pa icipa ed in he w i ing p ocess. All au ho s ead and app o ed he
inal manusc ip .
Au ho de ails
1 Fo ensic Psychia y, Helsinki Uni e si y and Helsinki Uni e si y Hospi al, PO
Box 590, 00029 HUS Helsinki, Finland. 2 Cen e o Li e Cou se Heal h Resea ch,
Uni e si y o Oulu, Oulu, Finland. 3 Medical Resea ch Cen e Oulu, Oulu Uni e ‑
si y Hospi al and Uni e si y o Oulu, Oulu, Finland. 4 School o Medicine, Tampe e
Uni e si y, Tampe e, Finland. 5 Depa men o Adolescen Psychia y, Tampe e
Uni e si y Hospi al, Tampe e, Finland. 6 Vanha Vaasa Hospi al, Vaasa, Finland.
Acknowledgemen s
We would like o acknowledge he au ho i ies a he Depa men o Psychia‑
y, Helsinki Uni e si y Hospi al, and Kellokoski Hospi al.
Compe ing in e es s
The au ho s decla e ha hey ha e no compe ing in e es s.
A ailabili y o da a and ma e ials
The da a con ibu ing o hese analyses a e s o ed in a secu e da abase a
Helsinki Uni e si y, Depa men o Psychia y, in acco dance wi h Eu opean
da a‑p o ec ion legisla ion. Resea che s and clinicians seeking access o
hese da a o academic non‑comme cial pu poses a e welcome o submi a
eques o he co esponding au ho (NL). All such eques s will be g an ed
whene e possible.
E hics app o al and consen o pa icipa e
The E hics Commi ee o he Helsinki and Uusimaa Hospi al Dis ic , Finland
e alua ed he s udy plan. Pe mission o conduc he s udy was g an ed by he
adminis a ion o he Helsinki and Uusimaa Hospi al Dis ic , Finland, and he
Na ional Ins i u e o Heal h and Wel a e, Finland. The s udy was ca ied ou in
acco dance wi h he Decla a ion o Helsinki. The p esen s udy is egis e ‑
based and he pa icipan s we e no con ac ed.
Funding
This s udy was unded by he Helsinki and Uusimaa Hospi al Dis ic . Howe e ,
he unde had no ole in he s udy design, he da a collec ion and analysis,
he decision o publish, o in he p epa a ion o he manusc ip .
Publishe ’s No e
Sp inge Na u e emains neu al wi h ega d o ju isdic ional claims in pub‑
lished maps and ins i u ional a ilia ions.
Recei ed: 27 Decembe 2016 Accep ed: 27 June 2017
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