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MENTAL ILLNESS AND VIOLENCE

Published 05 Nov 2020


MULTIPLE INTERACTING FACTORS CONTRIBUTE TO VIOLENT BEHAVIOR.

Public opinion surveys suggest that many people think mental illness and
violence go hand in hand. A 2006 national survey found, for example, that 60% of
Americans thought that people with schizophrenia were likely to act violently
toward someone else, while 32% thought that people with major depression were
likely to do so. In fact, research suggests that this public perception does not
reflect reality. Most individuals with psychiatric disorders are not violent.
Although a subset of people with psychiatric disorders commit assaults and
violent crimes, findings have been inconsistent about how much mental illness
contributes to this behavior and how much substance abuse and other factors do.

An ongoing problem in the scientific literature is that studies have used
different methods to assess rates of violence — both in people with mental
illness and in control groups used for comparison. Some studies rely on
"self-reporting," or participants' own recollection of whether they have acted
violently toward others. Such studies may underestimate rates of violence for
several reasons. Participants may forget what they did in the past, or may be
embarrassed about or unwilling to admit to violent behavior. Other studies have
compared data from the criminal justice system, such as arrest rates among
people with mental illness and those without. But these studies, by definition
involving a subset of people, may also misstate rates of violence in the
community. Finally, some studies have not controlled for the multiple variables
beyond substance abuse that contribute to violent behavior (whether an
individual is mentally ill or not), such as poverty, family history, personal
adversity or stress, and so on.

The MacArthur Violence Risk Assessment Study was one of the first to address the
design flaws of earlier research by using three sources of information to assess
rates of violence. The investigators interviewed participants multiple times, to
assess self-reported violence on an ongoing basis. They verified participants'
recollections by checking with family members, case managers, or other people
familiar with the participants. Finally, the researchers also checked arrest and
hospitalization records.

The study found that 31% of people who had both a substance abuse disorder and a
psychiatric disorder (a "dual diagnosis") committed at least one act of violence
in a year, compared with 18% of people with a psychiatric disorder alone. This
confirmed other research that substance abuse is a key contributor to violent
behavior. But when the investigators probed further, comparing rates of violence
in one area in Pittsburgh in order to control for environmental factors as well
as substance use, they found no significant difference in the rates of violence
among people with mental illness and other people living in the same
neighborhood. In other words, after controlling for substance use, rates of
violence reported in the study may reflect factors common to a particular
neighborhood rather than the symptoms of a psychiatric disorder.

Several studies that have compared large numbers of people with psychiatric
disorders with peers in the general population have added to the literature by
carefully controlling for multiple factors that contribute to violence.

In two of the best designed studies, investigators from the University of Oxford
analyzed data from a Swedish registry of hospital admissions and criminal
convictions. (In Sweden, every individual has a unique personal identification
number that allowed the investigators to determine how many people with mental
illness were convicted of crimes and then compare them with a matched group of
controls.) In separate studies, the investigators found that people with bipolar
disorder or schizophrenia were more likely — to a modest but statistically
significant degree — to commit assaults or other violent crimes when compared
with people in the general population. Differences in the rates of violence
narrowed, however, when the researchers compared patients with bipolar disorder
or schizophrenia with their unaffected siblings. This suggested that shared
genetic vulnerability or common elements of social environment, such as poverty
and early exposure to violence, were at least partially responsible for violent
behavior. However, rates of violence increased dramatically in those with a dual
diagnosis (see "Rates of violence compared").

Taken together with the MacArthur study, these papers have painted a more
complex picture about mental illness and violence. They suggest that violence by
people with mental illness — like aggression in the general population — stems
from multiple overlapping factors interacting in complex ways. These include
family history, personal stressors (such as divorce or bereavement), and
socioeconomic factors (such as poverty and homelessness). Substance abuse is
often tightly woven into this fabric, making it hard to tease apart the
influence of other less obvious factors.


RATES OF VIOLENCE COMPARED






ASSESSING RISK OF VIOLENCE

Highly publicized acts of violence by people with mental illness affect more
than public perception. Clinicians are under pressure to assess their patients
for potential to act in a violent way. Although it is possible to make a general
assessment of relative risk, it is impossible to predict an individual, specific
act of violence, given that such acts tend to occur when the perpetrator is
highly emotional. During a clinical session, the same person may be guarded,
less emotional, and even thoughtful, thereby masking any signs of violent
intent. And even when the patient explicitly expresses intent to harm someone
else, the relative risk for acting on that plan is still significantly
influenced by the following life circumstances and clinical factors.

History of violence. Individuals who have been arrested or acted violently in
the past are more likely than others to become violent again. Much of the
research suggests that this factor may be the largest single predictor of future
violence. What these studies cannot reveal, however, is whether past violence
was due to mental illness or some of the other factors explored below.

Substance use. Patients with a dual diagnosis are more likely than patients with
a psychiatric disorder alone to become violent, so a comprehensive assessment
includes questions about substance use in addition to asking about symptoms of a
psychiatric disorder.

One theory is that alcohol and drug abuse can trigger violent behavior in people
with or without psychiatric disorders because these substances simultaneously
impair judgment, change a person's emotional equilibrium, and remove cognitive
inhibitions. In people with psychiatric disorders, substance abuse may
exacerbate symptoms such as paranoia, grandiosity, or hostility. Patients who
abuse drugs or alcohol are also less likely to adhere to treatment for a mental
illness, and that can worsen psychiatric symptoms. Another theory, however, is
that substance abuse may be masking, or entwined with, other risk factors for
violence. A survey of 1,410 patients with schizophrenia participating in the
Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study, for
example, found that substance abuse and dependence increased risk of
self-reported violent behavior fourfold. But when the researchers adjusted for
other factors, such as psychotic symptoms and conduct disorder during childhood,
the impact of substance use was no longer significant.

Personality disorders. Borderline personality disorder, antisocial personality
disorder, conduct disorder, and other personality disorders often manifest in
aggression or violence. When a personality disorder occurs in conjunction with
another psychiatric disorder, the combination may also increase risk of violent
behavior (as suggested by the CATIE study, above).

Nature of symptoms. Patients with paranoid delusions, command hallucinations,
and florid psychotic thoughts may be more likely to become violent than other
patients. For clinicians, it is important to understand the patient's own
perception of psychotic thoughts, because this may reveal when a patient may
feel compelled to fight back.

Age and gender. Young people are more likely than older adults to act violently.
In addition, men are more likely than women to act violently.

Social stress. People who are poor or homeless, or otherwise have a low
socioeconomic status, are more likely than others to become violent.

Personal stress, crisis, or loss. Unemployment, divorce, or separation in the
past year increases a patient's risk of violence. People who were victims of
violent crime in the past year are also more likely to assault someone.

Early exposure. The risk of violence rises with exposure to aggressive family
fights during childhood, physical abuse by a parent, or having a parent with a
criminal record.


PREVENTING VIOLENCE

The research suggests that adequate treatment of mental illness and substance
abuse may help reduce rates of violence. For example, in one study, the CATIE
investigators analyzed rates of violence in patients who had earlier been
randomly assigned to antipsychotic treatment. (Patients' own recollections were
double-checked with family members.) This study found that most patients with
schizophrenia who took antipsychotics as prescribed were less likely to be
violent than those who did not. An exception to this general trend occurred in
participants who were diagnosed with a conduct disorder during childhood. No
medication proved better than the others in reducing rates of violence, but this
study excluded clozapine (Clozaril).

This is important because both the CATIE investigators and other researchers
cite evidence that clozapine appears more effective than other psychotics in
reducing aggressive behavior in patients with schizophrenia and other psychotic
disorders. One study found, for example, that patients with a diagnosis of
schizophrenia or another psychotic disorder who were treated with clozapine had
significantly lower arrest rates than those taking other drugs. The study was
not designed to determine whether this was due to the drug itself or the fact
that clozapine treatment requires frequent follow-ups that might encourage
patients to continue taking it as prescribed.

Indeed, as with psychiatric treatment in general, medication treatment alone is
unlikely to reduce risk of violence in people with mental illness. Interventions
ideally should be long-term and include a range of psychosocial approaches,
including cognitive behavioral therapy, conflict management, and substance abuse
treatment.

Of course, this sort of ideal treatment may be increasingly difficult to achieve
in the real world, given reductions in reimbursements for mental health
services, ever-shorter hospital stays, poor discharge planning, fragmented care
in the community, and lack of options for patients with a dual diagnosis. The
Schizophrenia Patient Outcomes Research Team (PORT) guidelines, for example,
outlined the type of multimodal treatment necessary to increase chances of full
recovery. Most patients with schizophrenia do not receive the kind of care
outlined in the PORT recommendations. Solutions to these challenges will arise
not from clinicians, but from policy makers.

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