Mental Illness and Violence

From the Rake’s Progress, William Hogarth, Bedlam, 1733

Bethlehem Hospital, (Bedlam) London, the source from which many of our stereotypes of the mentally ill have come.

Author’s Note: I published this post about two and a half years ago on Daily Kos following the Sandy Hook killings. However, it applies as much today as it did then and I am confident that no new data have been published to substantially change any of the conclusions. Much of the research described here was conducted by teams of Psychologists, Psychiatrists and Sociologists, funded by The MacArthur foundation, since the congress has prevented any government funding of gun violence research since 1996. As I heard from a leader of the Second Amendment Foundation, “Conducting research on gun violence is tantamount to taking our guns away.” Clearly, they know where the research would lead.

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There is rampant hysteria today about the mentally ill being dangerous and having access to guns. To some, the mentally ill are the major problem with gun violence. Take for example, Ann Coulter’s headline on Newsbusters.org: “Guns don’t kill people, the mentally ill do”.

Too often government policies are based on these erroneous beliefs as legislatures are spinning off new laws to constrain the mentally ill. New York State passed a law directing therapists to report any client thought to be “likely to engage in” violent behavior to the police. Such prediction is very difficult to do accurately and results in many false positives.

The impetus for the current flurry of concern is the Sandy Hook Elementary School shootings, coming on the tail of the Tucson and Aurora shootings. (to which I can now add, Colorado Springs, Umpqua Community College in Oregon, San Bernadino, ….) Contrary to the media hype, these horrific events are but a drop in the bucket of the scandalously high number of violent and murderous acts that happen in the U.S. daily. The vast majority of such acts of violence and murder are perpetrated by people who are not the seriously mentally ill. This is not to say that the perpetrators don’t have some of their own problems including anger, lack of self control, feelings of persecution and disenfranchisement, and misplaced desire for revenge, but most are not the seriously mentally ill.

Due to historical factors such as equating mental illness with evil and demon possession, along with disproportionate media coverage, the public has seriously over blown beliefs concerning the mentally ill and violence. Public perception is wrong and strong: 61% believe that people with schizophrenia were more likely to act violently to others, and 33% felt people with Major Depression were likely to be violent.

These beliefs are present throughout the media and popular culture. For example The Screen Actors Guild survey showed that characters in prime time TV portrayed as having mental illness are depicted as the most dangerous of all demographic groups: 60% are shown to be involved in crime or violence. Yet it is the currency of the high profile incidents along with the long standing superstition and stigma that pervades and molds the public’s and policy makers’ views of mental illness.

What are the facts?

There is now quite good epidemiological and population research both in the U.S. and abroad concerning the relationship between mental illness and violence that I will briefly review in an attempt to lay out the data as we know them today.

If you ask as many have, “Are the seriously mentally ill largely responsible for societal violence?” the answer is clearly and emphatically, “no.” Here we define Seriously Mentally Ill (SMI) as someone with a diagnosis of Schizophrenia, Bipolar Disorder, or Major Depression and related serious major mental disorders. Typically these are the people who are likely to end up in a mental hospital at some time in their lives. If you ask if SMI are disproportionately involved in violence, relative to the general population, you might get an answer of yes, or maybe, but only under certain circumstances. Taken without appropriate qualification, SMI is at best only slightly or not at all, disproportionately associated with violence. It is important to know what some of the qualifying circumstances are.

Until the past decade or so our data on SMI and violence was unclear and often contradictory. The extant studies were often restricted to certain locales and used convenience samples that were relatively easy to study. Most samples were not representative of all mentally ill individuals, but only of those with the highest risk of becoming dangerous, such as those who are hospitalized or arrested. Few studies assessed for the numerous socio-demographic, historical and clinical variables that themselves were significantly associated with violence. Thus, it was impossible to differentiate which factors were related to violent behavior and seldom were these variables all examined for their individual contributions. In the late 1990s, the MacArthur Foundation supported a series of studies that became the gold standard today for designing and conducting studies on violence and the mentally ill.

The MacArthur Violence Risk Assessment Study has produced a series of comprehensive studies taking into account the shortcomings of previous research. Their team of experts, headed by John Monahan, developed scientifically valid methods and procedures that have enabled replicable findings by others. These methods assess the major individual known risk factors for violence and their interactive relationships to the mentally ill.

Are Seriously Mentally ill patients dangerous and violence prone?

The first answer is at best, “marginally so” if we take into account whether they have some other more potent characteristics. The MacArthur studies and those that followed them find that the combination of a Serious Mental Illness diagnosis, along with a dual diagnosis of alcohol or substance abuse, is the most important combination for predicting violence from the mentally ill. This association is also found to hold across several U.S. communities studied as well as other countries including Sweden and Canada. And yet, people with these characteristics account for but a small fraction of violence in our societies.

Perhaps the most consistent and important finding of these and subsequent studies is that simply using the category of “SMI” grossly overestimates the role of mental illness in violence. A major conclusion from the MacArthur studies follows:

The prevalence of violence among patients discharged from a hospital and who do not have symptoms of substance abuse is about the same as the prevalence of violence among non-SMI other people living in their communities who do not have symptoms of substance abuse. That is, knowing that someone has just been released from a mental hospital does not help you predict violence unless you know that they also have a dual diagnosis of Substance Abuse. Although they do have an elevated risk for violence, relative to the general population, it is not different from those living in the same geographic and socioeconomic circumstances.

Thus, it is not SMI itself that is associated with violent behavior but its interaction with substance abuse along with a number of other factors including where they live when they return from a hospital stay.

What other variables contribute to predicting violence in the mentally ill?

The MacArthur studies also found a number of other independent risk factors that were statistically important in predicting violence in addition to substance abuse among the SMI. These factors include: Antisocial Personality Disorder, being male, and of younger age. Family experiences such as having been abused as a child and having a father who used drugs were also of importance as were having had prior arrests, difficulties with anger control, violent fantasies, and feeling threatened. Recent stressors such as divorce, victimization, and unemployment were also statistically related to violence among patients. These are the same factors that are predictive of violence in any group.

These studies have made it clear that simply having a SMI diagnosis tells us relatively little about whether a given person will act in a violent manner. Rather to understand the role of SMI in violence one must take into account these socio-historical, economic, and clinical factors. Given the newer methodologies, these findings have been substantively replicated now.

Another major clinical risk factor associated with SMI and violence is whether they are under treatment at the time and are complying with their medication regime. Thus treatment availability and maintenance is critically important.

Alcohol or other drug abuse problems combined with poor adherence to medication may signal a higher risk of violent behavior among persons with serious mental illness. Reduction of such risk may require carefully targeted community interventions, including integrated mental health and substance abuse treatment. The combination of medication noncompliance and alcohol or substance abuse problems was significantly associated with serious violent acts in the community, after sociodemographic and clinical characteristics were controlled.

Who are the victims?

In those cases where a SMI person does display violence, their actions are seldom random. Rather they typically involve family members (87%) and, occur at home as is true for most acts of violence in the community. In the MacArthur studies, only 10.7% of violent acts among discharged patients were toward complete strangers. Comparable figures for such violence toward strangers among community controls (non-patients) was 22.2%.Thus, the mentally ill are only half as likely to harm strangers as people from a general community population.

Most people with SMI are not violent and most violent acts are not committed by people with SMI. In fact, people with SMI are actually at higher risk of being victims of violence than perpetrators. One study by Teplin et al. found that those with SMI are 11 times more likely to be victims of violent crime than the general population. And another found victimization to be somewhat less but still the rate was two and a half times greater than in the general population–8.2 percent versus 3.1 percent. This heightened risk for victimization is likely in part due to often living in undesirable neighborhoods and being homeless.

Another sad truth is the SMI are often their own victim in that the most common form of violence associated with mental illness is not against others, but rather, against oneself. In 2007, there were almost 35,000 suicides, nearly twice the rate of homicides (14,612). Suicide is the 10th leading cause of death in the United States. Although we do not know the exact numbers of SMI who commit suicide, it is safe to say that unrecognized, untreated mental illness is a leading culprit. The major method of suicide is by firearms – over 50%.

The rate of suicide among patients diagnosed with Schizophrenia is estimated to be ~5%, much higher than the general population. The rate for major affective disorders such as Major Depression and Bipolar Disorder is even higher. Taken together, suicide takes a huge toll on SMI.

How much physical violence in our society can be attributed to persons with SMI?

Swanson and colleagues reported population attributable risks for self-reported physical violence.

For those with a major mental disorder, the population attributable risk for physical violence was 4.3%, indicating that violence in the community could be reduced by less than five percent if major mental disorders could be eliminated. The population attributable risk for those with a substance abuse disorder was 34%, and for those with a comorbid mental illness and substance abuse disorder it was 5%. Therefore, by these estimates, violence in the community might be reduced by only 10% if both major mental disorders and comorbid disorders were eliminated. However, violence could be reduced by over a third if substance abuse disorders were eliminated.
(Swanson JW. Mental disorder, substance abuse, and community violence: an epidemiologic approach. In: Monahan J, Steadman HJ, editors. Violence and mental disorder: developments in risk assessment.Chicago: University of Chicago Press; 1994. pp. 101–136)

 

A Canadian study similarly found 3% of violent crimes attributable to SMI and 7% to substance abusers. A study of Swedish patients found an attributable risk of 5.2% of patients including those with substance abuse disorders. So, the estimates from several studies and countries suggest that by removing the mentally ill from society, we could reduce violent crime by between 3 and 5%, leaving 95 to 97 percent of societal violence untouched.

So, Ann Coulter is wrong, Wayne LaPierre is wrong, and the general public is misinformed. The seriously mentally ill are not the major causes of violence in the U.S. or elsewhere in the world. Although some mentally ill are involved in violent acts, their participation has less to do with being mentally ill per se than it does with their family experience, past and current living circumstances, alcohol and drug abuse, and lack of adherence to a treatment program. Elimination of all serious mental illness at best would lower the violence rate by about 3 to 5%. Although this percentage is not to be ignored, the intense focus on such a small percentage of the problem detracts from the vast majority of the violence pie – the other 96%. And, recall that one third of violence risk is accounted for by alcohol and substance abuse.

Should we be putting our tax money, legislative, and policy efforts into registering the mentally ill, forcing therapists to report their clients to the police, and further stigmatizing and demonizing them? Should we allow lobbing efforts to prevail that maintain the status quo such as that promulgated by the NRA?

When a CDC study found that having a gun in the home, tripled the chances that a family member would get shot, the NRA stepped in. An Arkansas representative, Jay Dickey added language to a 1996 federal law that barred the CDC from conducting research that might be used ”to advocate or promote gun control.” We are fortunate that President Obama recently instructed the CDC to resume studying causes and prevention of gun violence. [Scientific American (editors), March 2013 issue, page 10.]

 

Where should we be putting our money and efforts to reduce violence?

Here are my data-based suggestions for combating violence of all kinds:

• Fund more violence research, particularly domestic violence, gun violence, and how these co-occur,

• Develop more treatment and prevention programs for alcohol and substance abuse, mental illness, and dual    diagnosis of mental illness and substance abuse,

• Enhance education of the public about the nature of mental illness, its causes and treatments, with a focus on    reducing its social stigma,

• Examine social policies that produce income inequality and other risk factors for violence that result from poverty and  homeless.