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Briefing Paper
Updated April 2007

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Victimization: One of the consequences of failing to treat individuals with severe psychiatric disorders

SUMMARY: Multiple studies have shown that individuals with severe psychiatric disorders are especially vulnerable to being victimized. This frequently involves acts such as theft of clothing or money but also includes assault, rape, or being killed. Women who have a severe psychiatric disorder are especially vulnerable. Some of the studies suggest that individuals who are victimized are less likely to have been compliant with their medication. This association is strongly supported by the 2002 North Carolina study by Hiday et al., which showed that individuals with severe psychiatric disorders who were on outpatient commitment, and thus were taking their medication regularly, were victimized only half as often as those who were not on outpatient commitment.

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• In New York, 20 females with a mean age of 31 hospitalized with schizophrenia were interviewed when they were no longer psychotic. Of the 20, 10 "reported having been raped at least once, with half of these claiming to have been raped more than once" as an adult.

Friedman S, Harrison G. Sexual histories, attitudes, and behavior of schizophrenic and "normal" women. Archives of Sexual Behavior 13:555–567, 1984.

• In Los Angeles, 278 "psychiatrically disabled" residents of board-and-care homes were interviewed. Two-thirds were men, and 63 percent had a diagnosis of schizophrenia. One-third of the 278 individuals "reported being robbed and/or assaulted during the preceding year." The victims of violent crimes had "higher overall psychopathology," suggesting either lack of treatment or poor response to treatment.

Lehman AF, Linn LS. Crimes against discharged mental patients in board-and-care homes. American Journal of Psychiatry 141:271–274, 1984.

• In New York, 949 homeless men were interviewed regarding having been assaulted or injured. Twelve percent of the men were psychotic, and this group was significantly more likely than the nonpsychotic men to have been robbed, beaten, threatened with a weapon, or injured (concussion or limb fractures).

Padgett DK, Struening EL. Victimization and traumatic injuries among the homeless: associations with alcohol, drug, and mental problems. American Journal of Orthopsychiatry 62:525–534, 1992.

• In France, 64 women with schizophrenia and 26 women with bipolar disorder were carefully questioned regarding their sexual histories. A total of 14 (22 percent) of the women with schizophrenia and 4 (15 percent) of the women with bipolar disorder had been raped as adults, compared with a rate of 8 percent in the general population. Nine of the 14 women with schizophrenia who had been raped had been raped multiple times. According to the authors, the women with schizophrenia who had been raped "belonged mainly to the group of schizophrenics with the longest duration of hospitalization, that is to say, probably to the most chronically and severely ill group."

Darvez-Bornoz J-M, Lemperiere T, Degiovanni A, Grillard P. Sexual victimization in women with schizophrenia and bipolar disorder. Social Psychiatry and Psychiatric Epidemiology 30:78–84, 1995.

• In Washington, D.C., 44 women with a serious mental illness (75 percent diagnosed with schizophrenia or bipolar disorder) who were "episodically homeless" were interviewed regarding physical and sexual assault during the periods of homelessness. Of the 44 women, "30% reported at least one incident of physical assault and 34% reported at least one sexual assault while homeless." Of the sexual assaults, 57 percent reported that it occurred on the street, and 55 percent reported that the perpetrators were strangers. The authors conclude that "for episodically homeless women with serious mental illness, the lifetime risk for violent victimization is so high that rape and physical battery are normative experiences."

Goodman LA, Dutton MA, Harris M. Episodically homeless women with serious mental illness: prevalence of physical and sexual assault. American Journal of Orthopsychiatry 65:468–478, 1995.

• In Philadelphia, 69 individuals who had been admitted to a psychiatric hospital were asked about having been victimized in the preceding year. Of the 69, 48 had been living with their families. Two-thirds had an affective disorder diagnosis and one-third had a schizophrenia-spectrum diagnosis. They had an average age of 32 years and 7 previous psychiatric hospitalizations, suggesting that as a group they were probably not compliant with their medication. Among the 48 who had been living with their families, 17 (35 percent) had been severely victimized by a family member within the past year. In this study, severe victimization was defined as "hitting, punching, choking, beating up, and threatening with or using a knife or gun." Among those who had been victimized, the majority "also reported being physically aggressive toward their family member in the year before the assessment." (See briefing paper "Violence and Untreated Severe Mental Illness.") Thus, we have an overall picture of individuals with severe psychiatric disorders and recurrent hospital admissions who are both being victimized by, and being assaultive toward, other family members. 

Cascardi M, Mueser KT, DeGiralomo J, Murrin M. Physical aggression against psychiatric inpatients by family members and partners. Psychiatric Services 47:531–-533, 1996.

• Goodman et al. published a review of studies of victimization of women with “serious mental illness.” They concluded that “a large proportion of women with a serious mental disorder are victimized repeatedly in the course of their lives.” In particular, “schizophrenia is a risk factor for adult abuse.” The reasons for this, according to the authors, are the following:

It seems likely that common cognitive and behavioral manifestations of schizophrenia—such as limited reality testing, impaired judgment, planning difficulties, and difficulty with social relationships—increase an individual’s vulnerability to physical abuse and to coercive or exploitative sexual relationships.

Goodman LA, Rosenberg SD, Mueser KT, Drake RE. Physical and sexual assault history in women with serious mental illness: prevalence, correlates, treatment, and future research directions. Schizophrenia Bulletin 23:685–696, 1997.

• In North Carolina, 331 individuals with severe psychiatric disorders (schizophrenia, schizoaffective disorder, affective disorders with psychotic features) were questioned about victimization in the 4-month period immediately preceding their psychiatric hospitalization. All 331 individuals had been referred for outpatient commitment, strongly suggesting that they were noncompliant with their medications. Of the 331 individuals, 27 (8.2 percent) had been the victim of a violent crime (assault, rape, or mugging) within the previous 4 months, a rate 2.7 times higher than the annual rate of violent criminal victimization in the United States. The authors point to factors that "probably caused underreporting of some victimization" and also note that the rate of violent victimization in North Carolina is lower than the rate for the United States as a whole. These facts, plus the fact that the study compared victimization for 4 months in the study population versus 1 year in the control population, all suggest that the difference between the patients and controls was substantially greater. Using a multivariate analysis, the two variables that most strongly predicted criminal victimization among these individuals with severe psychiatric disorders were occasional drug or alcohol use and homelessness during the 4-month period.

Hiday VA, Swartz MS, Swanson JW, Borum R, Wagner HR. Criminal victimization of persons with severe mental illness. Psychiatric Services 50:62–68, 1999.

• It was reported in a large study using the national case register in Denmark that men with schizophrenia had a significantly increased risk of being killed by others. The increased risk was similar to the risk experienced by male alcoholics. The authors of the study speculated that this increased risk of being killed may be associated with the high crime areas in which the men live; due to hostility provoked in others by their symptoms (e.g., paranoia); secondary to decreased awareness of their own safety; or associated with their concurrent use of alcohol or drug abuse.

Hiroeh U, Appleby L, Mortensen PB, Dunn G. Death by homicide, suicide and other unnatural causes in people with mental illness: a population-based study. Lancet 358:2110–2112, 2001.

• In Seattle between 1997 and 1999, 819 women who had been sexually assaulted were asked about their history of psychiatric disorders. Eighty of the women (10 percent) had been diagnosed with schizophrenia or schizoaffective disorder, and an additional 55 (6 percent) had been diagnosed with bipolar disorder or severe depression. Because of the way the study was carried out, the authors said they believed that “most likely we underreported the prevalence of major psychiatric diagnosis in this population.” Women with a severe psychiatric disorder, compared to those without such disorders, were significantly more likely to have been sexually assaulted by a stranger, assaulted by multiple assailants, and injured during the assaults. They were also more likely to have been homeless or to have spent time in jail. The authors concluded that “sexual assaults in women with a major psychiatric diagnosis are common” and “more violent” than in women without such diagnoses.

Eckert LO, Sugar N, Fine D. Characteristics of sexual assault in women with a major psychiatric diagnosis. American Journal of Obstetrics and Gynecology 186:1284–1291, 2002.

• In Los Angeles, 172 individuals with schizophrenia who were living in the community in stable housing were followed for 3 years. During that time 34 percent of them were victimized by violent crimes (robbery, assault or rape). Individuals who were victimized were more likely to have had more severe symptoms although medication compliance was not assessed in this study. The authors concluded: “This finding suggests that the most ill and vulnerable persons with schizophrenia are the most likely to be victimized.”

Brekke JS, Prindle C, Bae SW et. al. Risks for individuals with schizophrenia who are living in the community. Psychiatric Services 52:1358–1366, 2001.

• In Pittsburgh, 270 individuals with severe psychiatric disorders who had been recently discharged from psychiatric hospitals were followed for 10 weeks and compared with 477 neighborhood controls. During this 10-week period 15 percent of the psychiatrically ill individuals were violently victimized compared to 7 percent of the neighborhood controls.

Silver E. Mental disorder and violent victimization: the mediating role of involvement in conflicted social relationships. Criminology 40:191–211, 2002.

• In Baltimore, data on physical and sexual abuse were collected for 1 year on 3 groups of women who were also substance abusers: schizophrenia, non-psychotic affective disorders (e.g. depression), and not mentally ill. The results demonstrated “high rates of past year violent sexual and physical abuse” with significantly higher risks among the women with schizophrenia.

Gearon JS, Bellack AS, Brown CH. Sexual and physical abuse in women with schizophrenia: prevalence and risk factors. Schizophrenia Research 60:38, 2003.

• In a study in Connecticut, 207 patients with severe psychiatric disorders who were living in the community were followed for 1 years. Individuals who also were substance abusers had significantly more episodes of violent victimization then did the patients without substance abuse. Much of the victimization was said to be associated with “social isolation related to disorders such as schizophrenia [which] may lead persons with co-occurring disorders to make poor judgments about whom to trust.”

Sells DJ, Rowe M, Fisk D et. al. Violent victimization of persons with co-occurring psychiatric and substance use disorders. Psychiatric Services 54:1253–1257, 2003.

• In England 591 individuals with severe psychiatric disorders, mostly schizophrenia and schizoaffective disorder, were queried about violent victimization (e.g. assaulted, beaten, molested). In the past year 16 percent had experienced violent victimization, and it was most common in those who had more severe symptoms, had been homeless, abused alcohol or drugs, or who were themselves violent.

Walsh E, Moran P, Scott C et. al. Prevalence of violent victimization in severe mental illness. British Journal of Psychiatry 183:233–238, 2003.

• A National Crime Victimization Survey interviewed 936 patients with “chronic and severe mental illnesses.” “More than one quarter . . . [of them] had been victims of a violent crime in the past year, a rate more than 11 times higher than the general population.” The authors suggested that the study “may underestimate victimization.”

Teplin LA, McClelland GM, Abram KM et al. Crime victimization in adults with severe mental illness. Archives of General Psychiatry 62:911–921, 2005..

Assisted treatment reduces victimization

• In North Carolina, detailed information on victimization was obtained on 184 individuals with schizophrenia, schizoaffective disorder, and affective disorders, who were followed for one year. Eighty-five of the individuals were on outpatient commitment for part or all of the year and 99 were not. Victimization was classified as either a violent crime (e.g., assault, rape, or mugging) or a nonviolent crime (e.g., burglary, theft of money, being cheated) against the psychiatrically ill person. Among the 85 individuals on outpatient commitment, 24 percent were victimized, while among the 99 not on outpatient commitment, 42 percent were victimized. The authors noted: "Furthermore, risk of victimization decreased with increased duration of outpatient commitment." Individuals in the outpatient-commitment group were victimized significantly less often despite the fact that individuals in both groups received standard outpatient care and case management services. 

The authors suggest that "outpatient commitment reduces criminal victimization through improving treatment adherence, decreasing substance abuse, and diminishing violent incidents" that may evoke retaliation. They believe the reduction of victimization works as follows:

Medication adherence can be expected to reduce symptoms of severe mental illness and thus reduce victimization. Psychotic symptoms and bizarre behavior can lead to tense and conflictual situations, which, in turn, may result in a patient's victimization-either because others become violent toward the patient or because the patient lashes out physically and others react with stronger violence. By facilitating adherence and ensuring more consistent follow-up, outpatient commitment may lead to reduced symptoms, better functioning in social relationships, and improved judgment. In turn, these changes should lessen a person's vulnerability to abuse by others and lower the probability of becoming involved in dangerous situations where victimization is more likely.

Hiday VA, Swartz MS, Swanson JW, Borum R, Wagner HR. Impact of outpatient commitment on victimization of people with severe mental illness. Am J Psychiatry 159:1403–1411, 2002.

Anecdotally, the tragedies continue to accumulate…

• A man living in a Gospel Mission was found stabbed to death in an alley in Oregon.  His mother said he had no money and nowhere to go and that even if he wanted to call, he couldn't have remembered the numbers, he was so cognitively impaired.

Oregon Herald, September 12, 2005

• Underneath the Grand Central Parkway in Queens, New York, a delusional and 44-year-old homeless man was fatally shot by a fellow homeless man whom he had befriended.

New York Daily News, November 14, 2004

• A homeless woman suffering bipolar disorder was run over by an 18-wheeler as she crossed the street in Fort Worth, Texas.

Houston Chronicle, July 3, 2004

• In San Francisco, the director of a shelter for homeless women said: "I know one woman who has been raped 17 times. She doesn’t report it because it’s just what happens out there."

San Francisco Chronicle, Dec. 18, 1988

• In New York, a graduate of Brown University who had suffered from a "nervous breakdown" and was homeless, was stabbed to death in a robbery attempt.

The New York Times, Nov. 20, 1990

• In New York, seriously mentally ill individuals living in homeless shelters are said to be "easy marks for thieves and other criminals who live there. . . . Those who receive social security disability checks become targets for muggers. . . . There is a hierarchy among the shelter clients, and the visibly mentally ill are the lowest caste, untouchables among the outcasts."

The New York Times, Jan. 12, 1992

• In New York, a homeless man experiencing auditory hallucinations was attacked by four teenage boys and jumped to his death to escape them.

The New York Times, Sept. 7, 1995

 

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