From the Editor

What’s the connection between mental illness and violence?

For years, the Hollywood depiction was black and white: mental illness caused brutal violent behaviour. And maybe society held those views, too – think of the old newspaper headlines talking about ‘psycho killers.’ Times have changed. Hollywood is slowly abandoning the caricatures; newspapers discuss violence against the mentally ill. But to answer this question, of course, we need to look to studies and journals, not the silver screen and journalism, and understand that the relationship between mental illness and violence is much more nuanced.

Hollywood and mental illness: room for improvement

This week, we review two papers. The first, from Psychiatric Services, considers different types of violence and mental illness. No surprise here: like other studies, the authors show that those with mental disorders are more likely to be victims of violence rather than violent to others. But the authors note a larger picture of violence. This short paper is far-reaching in its findings.

The Canadian Journal of Psychiatry’s February issue considers violence and schizophrenia (part of the In Review Series). The Quinn and Kolla paper presents a thoughtful review of the literature for evidence-based treatments for violence in schizophrenia.


Violence and Mental Illness

“Violence to Others, Violent Self-Victimization, and Violent Victimization by Others Among Persons With a Mental Illness”

John Monahan, Roumen Vesselinov, Pamela Clark Robbins, Paul S. Appelbaum

Psychiatric Services, 1 February 2017 In Advance

Violence to others by persons with a mental illness affects not only those who are victimized. It also fuels stigmatizing public perceptions of mental illness and is often invoked to justify fear-based mental health policies, such as loosening standards for public reporting of protected health information. Given these profound sequelae, it is not surprising that over the past several decades, an enormous research literature has focused on the assessment and management of the risk that persons with a mental illness will commit violence to others in the community.

Violence directed at others, however, is not the only form of violence that may be associated with mental illness. In fact, the ‘lived experience’ of violence among people with a mental illness includes two additional forms of violence. By simultaneously taking into account all three forms of violence, a more scientifically inclusive and clinically credible account of violence among persons with mental illness might emerge.

The first additional association between mental illness and violence reflects violence directed at oneself. Violent self-victimization—violence in which a patient is both the perpetrator and the victim, such as attempted suicide or other physically self-harming behavior—has long been recognized as a serious clinical concern, with most mental disorders associated with increased rates of suicide and self-injury.

The second additional association between mental illness and violence reflects violence directed by others at persons with a mental illness. Although this type of violence is studied much less frequently than other forms of violence associated with mental illness, patients with a mental illness are violently victimized by others in the community at a higher rate than the general population, a phenomenon that has attracted increased empirical attention in recent years.

To our knowledge, this is the first study to use a single data set, the MacArthur Violence Risk Assessment Study, to examine simultaneously the prevalence and characteristics of all three forms of violence involving people with a mental illness.

John Monahan

So begins a new paper by Monahan et al. These introductory paragraphs do an excellent job of providing the context for the study.

Here’s what they did:

· Data was drawn from the MacArthur Violence Risk Assessment Study which “involved a follow-up sample of 951 patients who had been discharged from acute civil inpatient facilities at three U.S. sites.”

· Participants were between 18 and 40. Inclusion criteria included diagnoses of bipolar, schizophrenia, depression, personality disorders.

· Violence towards others was determined by interviews with patients, interviews with people knowledgeable about them, and official records (like hospital records). Violent self-victimization by patients and violent victimization of patients were “measured by means of a structured interview…”

· Participants were seen every 10 weeks for a year after discharge.

· Violence was defined as “acts of battery, sexual assaults, assaultive acts that involved a weapon, or threats made with a weapon in hand.”

Here’s what they found:

· “One year after discharge, the prevalence rate for violence to others was 28% (N=262); violent self-victimization, 23% (N=217); and violent victimization by others, 43% (N=405).”

· “One-year post-discharge prevalence was 58% (N=555) for involvement in at least one form of violence, 28% (N=262) for involvement in at least two forms of violence, and 7% (N=67) for involvement in all three.”

· Violence was linked to physical abuse in childhood. Also: “The patients involved in at least one form of violence were more likely to report having been sexually abused as a child compared with those who were uninvolved in violence, but this comparison failed to reach statistical significance for patients involved in all three forms of violence.”

· Violence was linked with substance use and mental illness, though the pattern was complicated: “Patients diagnosed as having a major disorder and a substance use disorder constituted the largest proportion of both the group involved in at least one form of violence and the group involved in all three forms of violence, but the proportions of patients who had both a major disorder and a substance use disorder was not significantly different between either of the groups involved in at least one form of violence and the group that was uninvolved in violence.”

They note:

Most patients (58%) experienced at least one form of violence—whether as perpetrator, as victim, or in the case of self-harm, as both perpetrator and victim. Over one-quarter (28%) of patients experienced at least two forms of violence, and 7% of patients experienced all three forms of violence.

The authors see practical implications for the results:

For patients who screen positive for one or more forms of violence, clinicians should consider both treatment and preventive implications. For example, patients who have been violently victimized by others might benefit from trauma-informed treatment and, for those who are homeless, from efforts to obtain adequate housing, given that being domiciled reduces rates of victimization. The co-occurrence of several forms of violence involvement may require a package of interventions with components geared to each.

A few thoughts:

1. A good paper – and an important paper.

2. I’ll return to my first comment: those with mental disorders are more likely to be victims of violence rather than violent to others. But this paper pushes further, and thus adds nicely to the literature. The paper notes three types of violence, offering a more complete picture. And what a picture it is: whether it is violence to others, themselves, or being a victim, the post-discharge world is coloured by violence.

3. The authors make several thoughtful comments in conclusion. The call for “a package of interventions” is particularly interesting.

4. We shouldn’t whitewash the results, of course. Some with mental illness are violent to others. What are evidence-based approaches to help them? Our next paper reviews the literature (with a focus on schizophrenia).

Violence and Schizophrenia

“From Clozapine to Cognitive Remediation: A Review of Biological and Psychosocial Treatments for Violence in Schizophrenia”

Jason Quinn and Nathan J. Kolla

The Canadian Journal of Psychiatry, February 2017

Although most people with schizophrenia (SCZ) are not violent, SCZ is still a risk factor for violence. Epidemiological evidence confirms that men and women with SCZ are at elevated risk of conviction for violent offenses even after controlling for substance misuse and personality disorders. The risk of committing homicide is even greater among persons with SCZ compared with the general population. However, violence in SCZ frequently occurs in clinical settings, and much of this violence takes the form of physically assaultive behaviour directed at mental health professionals.

Effective treatment of violence and aggression in SCZ has the potential to lead to several positive outcomes. First, it would decrease victimization of the perpetrators that is closely linked to their own violent behaviour. Second, it would result in reduced victim injury. Third, stigma against patients with SCZ and other psychiatric illness would diminish. Fourth, the financial cost of incarcerating and hospitalizing offenders would decrease. Fifth, successful treatment could reduce crime rates.

Nathan J. Kolla

So begins a short, highly readable paper by Quinn and Kolla. They review different interventions, from rTMS to CBT.

Briefly, here’s what they did: drawing on a broad search using MEDLINE and PsychINFO, they then narrowed the number of studies with inclusion criteria: “publications with quantitative data, relatively recent publications…, violence as an outcome measure,” etc.; and then applied the Oxford Centre for Evidence-Based Medicine rating scheme.

What did they find? “This review provided an overview of the pharmacologic and psychosocial interventions for violence in SCZ. In Canada, as in many Western jurisdictions, persons with SCZ who commit violent offenses often attract significant media and political attention. The relative dearth of studies, particularly RCTs, that have investigated potential treatments for violence in SCZ is thus surprising.”

Of course, the author were able to make some observations based on their review: Clozapine has evidence; rTMS doesn’t; psychosocial interventions are mixed in effectiveness.

A few thoughts:

1. This is a good paper.

2. Many studies conclude with a call for action. But as we consider ways to reduce the large number of people with mental illness in our prison system, the advocacy of more (and better) research in this area seems reasonable – and, potentially, cost saving over time.

3. Clozapine has great evidence in reducing violence in those with schizophrenia. As the authors note in their review: “The findings from these robust studies are notable in that they demonstrated the superiority of clozapine over other second-generation and first-generation antipsychotics in reducing acute aggression.” I’ll return to a comment I’ve made before: the best drugs in psychiatry pre-date the psychopharmacology revolution.

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.