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Briefing Paper
Updated April 2007
Violent behavior: One of the consequences of failing to treat individuals with severe psychiatric disorders
SUMMARY: It is well known that the two major demographic predictors of violent behavior are male sex and younger age. It is also known that the two major clinical predictors of violent behavior are past history of violence and substance abuse (alcohol and/or drug). Recent studies have established that being severely mentally ill and not taking medication is a third major clinical predictor of violent behavior.
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Steadman HJ, Mulvey EP, Monahan J, et. al. Violence by people discharged from acute psychiatric impatient facilities and by others in the same neighborhoods. Archives of General Psychiatry 55:393–401, 1998.
Sosowsky, L. Explaining the increased arrest rate among mental patients: A cautionary note. American Journal of Psychiatry 137:1602–1605, 1980.
- A New York State study compared homicides committed by mentally ill persons in the years prior to widespread deinstitutionalization (1963-69) with the years during widespread desinstitutionalization (1970-1975). There was a significant increase in homicides in the latter period. The authors conlude “that closer follow-ups of psychotic patients, especially schizophrenics, could do a lot to improve the welfare of the patient and community.”
Grunberg F, Klinger BI, Grumet BR. Homicide and community-based psychiatry. Journal of Nervous and Mental Disease 166:868–874, 1978.
Rabkin J. Criminal behavior of discharged mental patients: A critical appraisal of the research. Psychological Bulletin 86:1–-27, 1979.
Swanson JW, Hozer CD, Ganju VK, et. al. Violence and psychiatric disorder in the community: Evidence from the Epidemiologic Catchment Area surveys. Hospital and Community Psychiatry 41:761–770, 1990.
Swanson J, Estroff S, Swartz M, et. al. Violence and severe mental disorder in clinical and community populations: The effects of psychotic symptoms, comorbidity, and lack of treatment. Psychiatry 60:1–22, 1997.
Yesavage, J.A. Inpatient violence and the schizophrenic patient: An inverse correlation between danger-related events and neuroleptic levels. Biological Psychiatry 17:1331–-1337, 1982.
Smith LD. Medication refusal and the rehospitalized mentally ill inmate. Hospital and Community Psychiatry 40:491–496, 1989.
Taylor P. Motives for offending amongst violent and psychotic men. British Journal of Psychiatry 147:491–498, 1985.
Steinwachs DM, Kasper JD, Skinner EA. Family perspectives on meeting the needs for care of severely mentally ill relatives: A national survey. Arlington, VA: National Alliance for the Mentally Ill, 1992.
- A 9 to 12 year follow-up of 192 men with schizophrenia who had been detained by the Secret Service when they had presented themselves at the White House with delusional demands found that they had a subsequent arrest rate for violent crimes 1.6 times (no past history of violence) to 4.8 times (with a past history of violence) the general population.
Shore D, Filson CR, Rae DS. Violent crime arrest rates of White House case subjects and matched control subjects. American Journal of Psychiatry 147:746–750, 1990.
- A study of 133 outpatients with schizophrenia showed that "13 percent of the study group were characteristically violent." Having inadequately treated symptoms of delusions and hallucinations was one of the predictions of violent behavior. Specifically, "71 percent of the violent patients…had problems with medication compliance, compared with only 17 percent of those without hostile behaviors," a difference which was statistically highly significant (p< 0.001).
Bartels J, Drake RE, Wallach MA, et. al. Characteristic hostility in schizophrenic outpatients. Schizophrenia Bulletin 17:163–171, 1991.
Lindqvist P, Allebeck P. Schizophrenia and crime: A longitudinal follow-up of 644 schizophrenics in Stockholm. British Journal of Psychiatry 157:345–350, 1990.
Hodgins, S. Mental disorder, intellectual deficiency, and crime. Archives of General Psychiatry 49:476–483, 1992.
Monahan J. Mental disorder and violent behavior. American Psychologist 47:511–-521, 1992.
- Among 20 individuals who pushed or tried to push another person in front of the subway in New York, all except one was severely mentally ill and offered motives directly related to their untreated psychotic symptoms.
Martell DA, Dietz PE. Mentally disordered offenders who push or attempt to push victims onto subway tracks in New York City. Archives of General Psychiatry 49:472–475, 1992.
Link BG, Andrews H, Cullen FT. The violent and illegal behavior of mental patients reconsidered. American Sociological Review 57:275–292, 1992.
- A study of 538 individuals with schizophrenia living in London reported that the men had a 3.9 times and women 5.3 times greater risk for conviction for assault and serious violence compared to a control group with other psychiatric diagnoses.
Wesseley SC, Castle D, Douglas AJ, et. al. The criminal careers of incident cases of schizophrenia. Psychological Medicine 24, 483-502, 1994.
- A study of 348 inpatients in a Virginia state psychiatric hospital found that patients who refused to take medication "were more likely to be assaultive, were more likely to require seclusion and restraint, and had longer hospitalizations."
Kasper JA, Hoge SK, Feucht-Haviar T, et. al. Prospective study of patients’ refusal of antipsychotic medication under a physician discretion review procedure. American Journal of Psychiatry 154:483–489, 1997.
- A study in Switzerland compared 282 men with schizophrenia with a matched control group in the general population. The patients were five times more likely to have been convicted of violent crimes, mostly "assaults resulting in bodily harm." The more acutely ill the patient was, the more likely he was to have been violent.
Modestin J, Ammann R. Mental disorder and criminality: Male schizophrenia. Schizophrenia Bulletin 22: 69–82, 1996.
- A study of homicides in Finland reported that "the risk of committing a homicide was about 10 times greater for schizophrenia patients of both genders than it was for the general population." For men "schizophrenia without alcoholism increased the odds ratio more than 7 times; schizophrenia with coexisting alcoholism more than 17 times."
Eronen M, Tiihonen J, Hakola P. Schizophrenia and homicidal behavior. Schizophrenia Bulletin 22:83–89, 1996.
- In another study in Finland an unselected birth cohort of 11,017 individuals was followed for 26 years. Men with schizophrenia without alcoholism were 3.6 times more likely to commit a violent crime than men without a psychiatric diagnosis. Men with both schizophrenia and alcoholism were 25.2 times more likely to commit a violent crime.
Rasanen P, Tiihonen J, Isohanni M, et.al. Schizophrenia, alcohol abuse, and violent behavior: a 26-year follow-up study of an unselected birth cohort. Schizophrenia Bulletin 24:437–441, 1998.
Steadman HJ, Mulvey EP, Monahan J, et. al. Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighborhoods. Archives of General Psychiatry 55:393–401, 1998.
Taylor PJ, Leese M, Williams D, et. al. Mental disorder and violence. British Journal of Psychiatry 172:218–226, 1998.
Belfrage H. A ten-year follow-up of criminality in Stockholm mental patients. British Journal of Criminology 38:145–155, 1998.
Swartz MS, Swanson JW, Hiday VA, et. al. Violence and severe mental illness: The effects of substance abuse and nonadherence to medication. American Journal of Psychiatry 155:226–231, 1998.
Swanson JW, Swartz MS, Essock SM et al. The social-environmental context of violent behavior in persons treated for severe mental illness. American Journal of Public Health 92:1523–1531, 2002.
Arango C, Barba AC, Gonzalez-Salvador T, et. al. Violence in schizophrenic inpatients: A prospective study. Schizophrenia Bulletin, 25:493–503,1999.
- A study in Ohio compared 122 patients with schizophrenia who had committed violent acts with 111 patients with schizophrenia who had not committed such acts. The violent patients had significantly more prominent symptoms and significantly less awareness of their illness.
Friedman L, Hrouda D, Noffsinger S et. al. Psychometric relationships of insight in patients with schizophrenia who commit violent acts. Schizophrenia Research 60:81, 2003.
- A study in New York assessed 60 severely mentally ill men who had been charged with violent crimes. The author reported that medication noncompliance and lack of awareness of illness both played significant roles in causing the men’s violent behavior.
Alia-Klein N. Violence and psychosis in relationship to insight into illness and medication compliance. Submitted for publication.
- A study of 961 young adults in New Zealand reported that individuals with schizophrenia and associated disorders were two-and-one-half times more likely than controls to have been violent in the past year. If the person was also a substance abuser their incidence of violent behavior was even higher.
Arseneault L, Moffitt TE, Caspi A et. al. Mental disorders and violence in a total birth cohort. Archives of General Psychiatry 57:979-986, 2000.
- In reviewing many of these studies in 1992 Professor John Monahan concluded: "The data that have recently become available, fairly read, suggest the one conclusion I did not want to reach: Whether the measure is the prevalence of violence among the disordered or the prevalence of disorder among the violent, whether the sample is people who are selected for treatment as inmates or patients in institutions or people randomly chosen from the open community, and no matter how many social and demographic factors are statistically taken into account, there appears to be a relationship between mental disorder and violent behavior."
Monahan J. Mental disorder and violent behavior. American Psychologist 47:511–521,1992.
- In a 1996 editorial reviewing such studies Dr. Peter Marzuk added: "In the last decade, however, the evidence showing a link between violence, crime, and mental illness has mounted. It cannot be dismissed; it should not be ignored."
Marzuk PM. Violence, crime, and mental illness. Archives of General Psychiatry 53:481–486, 1996.
- A 2001 review article on violence and schizophrenia, authored by researchers at the Institute of Psychiatry in London, concluded: "It is now generally accepted that people with schizophrenia, albeit by virtue of the activity of a small subgroup, are significantly more likely to be violent than members of the general population, but the proportion of societal violence attributable to this group is small." The authors also noted that "comorbid substance abuse considerably increases the risk." They emphasized that the proportion of total violence in society attributable to schizophrenia is small, specifically "below 10 percent."
Walsh E, Buchanan A, Fahy T. Violence and schizophrenia: examining the evidence. British Journal of Psychiatry 180: 490–495, 2001.
- Compared to substance abuse, severe mental illness contributes a relatively small percentage to total violence. Professor John Monahan cited a study that estimated "that 3 percent of the variance in violent behavior in the United States is attributable to mental disorder."
Monahan J. Mental illness and violent crime. National Institute of Justice Research Preview, October 1996.
- A 1988 Department of Justice study reported that individuals with a history of mental illness (not including drug or alcohol abuse) were responsible for 4.3 percent of the homicides in the United States, or 897 out of 20,860. In instances in which the homicide occurred among family members the percentage was much higher, e.g., in 25 percent of cases in which an individual killed his/her parent, that individual was mentally ill. If the 4.3 percentage held in 1993, the total mental illness-related homicides would have been 1,055 (4.3 percent of 24,530). It seems reasonable to assume that most of these would have been preventable if the individual had been receiving psychiatric treatment.
Dawson JM, Langan PA. Murder in families. U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, 1994.
- A 1985 study reported that 10 percent (7 out of 71) of all homicides in 1978–1980 in Contra Costa County in California were carried out by individuals diagnosed with schizophrenia. All had been evaluated psychiatrically prior to the crime and had refused medication.
Wilcox DE. The relationship of mental illness to homicide. American Journal of Forensic Psychiatry 6:3–15, 1985.
- In 2005, there were 16,192 homicides in the United States. If individuals with severe psychiatric disorders were responsible for only 5 percent of these, that would be almost 900 homicides.
- In countries such as the United States, where violence is relatively common, the percentage of violent acts attributable to individuals with severe psychiatric disorders is comparatively low, probably no more than 5 percent. In many other countries where violence is less common, the percentage of violent acts attributable to individuals with severe psychiatric disorders may be proportionately greater. Thus, in New Zealand, a study reported that "just over 10 percent of past-year violence committed by these young adults was attributable to schizophrenic spectrum disorders."
Walsh E, Buchanan A, Fahy T. Violence and schizophrenia: examining the evidence. British Journal of Psychiatry 180: 490–495, 2001.
- There is very little data which can be used to estimate the percentage of severely mentally ill individuals who become violent. The best study used the Danish psychiatric case register, covering the whole country, and convictions for criminal offenses. Between1978 and 1990 6.7 percent of males and 0.9 percent of females with "major mental disorders" (psychoses) were convicted of a violent crime ("all offenses involving interpersonal aggression or a threat thereof"), compared with 1.5 percent males and 0.1 percent females among individuals with no psychiatric diagnosis. Since these are only convictions, it can be assumed that another unknown percentage committed a violent act for which they were not charged or convicted.
Hodgins S, Mednick SA, Brennan PA, et.al. Mental disorder and crime. Archives of General Psychiatry 53:489–496, 1996.
- The incidence of violent behavior among severely mentally ill individuals in the studies discussed under II above includes:
Angermeyer MC, Matschinger H. The effect of violent attacks by schizophrenic persons on the attitude of the public towards the mentally ill. Social Science and Medicine 43:12:1721–1728, 1996.
- A study using university volunteers demonstrated that reading a newspaper article reporting a violent crime committed by a mental patient led to increased "negative attitudes toward people with mental illnesses."
Thorton JA, Wahl OF. Impact of a newspaper article on attitudes toward mental illness. Journal of Community Psychology 24:17–25, 1996.
- Such studies suggest that it is futile to try and decrease stigma against individuals with mental illness until the problem of violence is addressed. This was noted as early as 1981 by Dr. Henry Steadman who observed:
"Recent research data on contemporary populations of ex-mental patients supports these public fears [of dangerousness] to an extent rarely acknowledged by mental health professionals. . . .It is [therefore] futile and inappropriate to badger the news and entertainment media with appeals to help destigmatize the mentally ill."
Steadman, HJ. Critically reassessing the accuracy of public perceptions of the dangerousness of the mentally ill. Journal of Health and Social Behavior 22. 31–316, 1981.
- In 1992 Dr. John Monahan added:
"The data suggest that public education programs by advocates for the mentally disordered along the lines of ‘people with mental illness are no more violent than the rest of us’ may be doomed to failure….And they should: the claim, it turns out, may well be untrue."
Monahan J. Mental disorder and violent behavior. American Psychologist 47:511–521, 1992.
- The 1999 Surgeon General's Report on Mental Health noted that "the perception of people with psychosis as being dangerous is stronger today than in the past.... People with mental illness, especially those with psychosis, are perceived to be more violent than in the past" (Surgeon General's Report, p. 7).
See the briefing paper "Stigma and Violence" for a fuller discussion of this issue.
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