Major Problem Often Overlooked When Linking Violence, Illness

Public and professional attention in recent years has tended to focus on whether people with mental illness are more likely than others to commit acts of violence, but a new study suggests that violent victimization of these individuals may be the greater public health problem.

A literature review of studies published since 1990 on the perpetration of violence by, and violent victimization of, mentally ill individuals indicates that victimization is considerably more common than perpetration.

The study was published in the February Psychiatric Services as part of a special issue on violence and mental illness.

Among outpatients, 2 percent to 13 percent had perpetrated violence in the prior six months to three years, compared with 20 percent to 34 percent who had been violently victimized. Studies combining outpatients and inpatients reported that 12 percent to 22 percent had perpetrated violence in the prior six to 18 months, compared with 35 percent who had been a victim in the preceding year.

“Although society may regard persons with mental illness as dangerous criminals, our review of the literature shows that violent victimization of persons with severe mental illness is a greater public health concern than perpetration of violence,” wrote lead author Linda Teplin, Ph.D., and colleagues in their report.

Along with other reports examining issues associated with violence and its relationship to mental illness, the study by Teplin and colleagues suggests that that relationship—which has attracted the attention of policymakers, professionals, and the general public—may be less straightforward than typically thought.

The journal also includes a print “debate” between the authors of the 1998 MacArthur Violence Risk Assessment Study and psychiatrist Fuller Torrey, M.D., and attorney Jonathan Stanley, J.D., about the methodology and interpretation of that report (see Findings of Landmark Study Still Provoke Heated Debate).

This seminal report, which was published in the Archives of General Psychiatry, has been cited by many advocates to show that individuals with mental illness are not more likely than those in the general population to commit acts of violence.

But Torrey and Stanley argued that such an interpretation has obscured the real risks of violence associated with mental illness—especially untreated mental illness—and claim that unpublished data from the study would have shown the critical importance of treatment.

Their article appears in Psychiatric Services as a point-counterpoint, with Torrey and Stanley's claims followed by responses from MacArthur study authors John Monahan, Ph.D., and Henry Stedman, Ph.D.

Torrey is executive director of the Stanley Medical Research Institute and president of the Treatment Advocacy Center, an organization that advocates for laws permitting involuntary treatment of patients with severe mental illness.

Another article in the journal, by Alec Buchanan, M.D., Ph.D., of Yale University, showed that the ability of mental health professionals to predict which patients are at risk to be violent has improved over the last 30 years.

But the article by Jeffrey Swanson, Ph.D., pointed out that the accuracy of even the best such screening test is substantially below what would be considered acceptable in other areas of medicine, such as oncology.

He is a professor of psychiatry and behavioral sciences at Duke University Medical Center.

“Mental health professionals are concerned about the recovery of individuals with mental disorders, and we must protect them from harm,” Howard Goldman, M.D., Ph.D., editor of Psychiatric Services, wrote in an accompanying editorial.

“But we also have an obligation to protect society from dangers that might be associated with mental illness,” Goldman continued.“ Historically our society has been more concerned about its own protection than about the protection of psychiatric patients. But it is imperative that we get the balance right. We need a more nuanced view of the association between violence and mental illness—and that is the editorial intent behind this special issue.”

Yet victimization appears to be a subject that has only rarely crossed the minds of researchers: while there were 31 studies of violence perpetration by people with mental illness, there were only 10 studies on victimization, and few studies looked at both phenomena, according to the study by Teplin and colleagues.

They searched MEDLINE, PsycINFO, and Web of Science publications for empirical investigations of recent prevalence or incidence of perpetration or victimization among persons with severe mental illness.

With regard to perpetration of violence, studies of inpatients with severe mental illness show that perpetration of violence is most prevalent among committed patients before hospitalization, when violence may have precipitated their commitment.

Prevalence ranged from 14.2 percent among voluntary inpatients in the month before hospitalization to 50.4 percent among committed inpatients in the four months before hospitalization.

Only one study of adults in treatment for severe mental illness investigated the incidence of recent violent victimization. That study, titled“ Crime Victimization in Adults With Severe Mental Illness: Comparison With the National Crime Victimization Survey,” was published in the August 2005 Archives of General Psychiatry. Teplin and colleagues examined 936 randomly selected persons with severe mental illness from a random sample of treatment facilities—outpatient, day treatment, and residential treatment—in Chicago.

There were 168.2 incidents of violent victimization per 1,000 persons per year, more than four times the rate in the general population. Incidence ratios remained statistically significant even after the analysis controlled for sex and race/ethnicity.

All 10 studies on victimization examined prevalence of self-reported victimization (including the Teplin study, which also reported incidence), with prevalence varying from study to study by type of victimization and by type of population sample. But irrespective of the type of sample and type of victimization, prevalence was much higher in all studies than in the general population, as found in the National Crime Victimization Study.

In this month's Psychiatric Services article, Teplin and colleagues cited research pointing to a theoretical model whereby social disorganization and poverty may increase a person's vulnerability to both victimization and propensity to perpetrate violence.

“Repeated victimizations may lead to suspicion and mistrust, which in turn may lead to conflictive and stressful situations—in short, a cycle of victimization and perpetration,” they wrote.

They argued for a new focus on victimization and on research that can help disentangle the complex relationship between mental illness, violence perpetration, and violent victimization.

“Ironically, the discipline's focus on the perpetration of violence among inpatients may contribute to the negative stereotypes of persons with severe mental illness, which are often based on the label of 'mental patient,' not on observed behavior,” they stated. “We must balance the dual public health concerns of protecting the safety of the public and protecting persons with severe mental illness from criminal victimization.”

The FebruaryPsychiatric Servicesis posted at<http://ps.psychiatryonline.org/archive/>. An abstract of “Crime Victimization in Adults With Severe Mental Illness: Comparison With the National Crime Victimization Survey” is posted at<http://archpsyc.ama-assn.org/cgi/content/abstract/62/8/911>.▪