Mental illness and violence: an epidemiological appraisal of the evidence

OBJECTIVE: To conduct a critical review of the literature on the matter of mental illness and violence, to examine whether there is enough evidence to establish a causal link, and to provide epidemiological background to measure the risk to the population. METHOD: Based on a computerized search of the literature on mental illness and violence previously conducted for Health Canada, studies in the area were critically reviewed and divided into 3 main categories: 1) studies of criminal and violent behaviour among psychiatric patients, 2) studies of psychiatric illness among offenders (prevalence studies in institutions, analytical studies, and community follow-up of offenders), and 3) epidemiological community-based studies on the issue of mental illness and violence (police-citizen encounters, representative samples, and other epidemiological studies). Causality rules and measures of risk were then applied to the evidence elicited. RESULTS: The review of the literature suggests that only a small minority of hospitalized patients, typically those suffering from acute psychotic symptoms, are involved in violent incidents. Formerly hospitalized patients are at a higher risk of committing violence if they are not properly treated and are experiencing threat/control-override psychotic symptoms. Substance abuse disorders significantly raise the risk for violence. Family members are the most at risk of being victimized. CONCLUSION: An association exists between mental illness and violence, but the many covariations that naturally affect the equation between them introduce uncertainties in establishing causality.     

Does psychiatric disorder predict violent crime among released jail detainees? A six-year longitudinal study.

Examined whether jail detainees with schizophrenia, major affective disorders, alcohol or drug use disorders, or psychotic symptoms (hallucinations and delusions) are arrested more often for violent crimes 6 yrs after release than are detainees with no disorders. Trained interviewers assessed 728 randomly selected male jail detainees using the National Institute of Mental Health Diagnostic Interview Schedule and then obtained follow-up arrest data for 6 yrs. Neither severe mental disorder nor substance abuse or dependence predicted the probability of arrest or the number of arrests for violent crime. Ss with symptoms of both hallucinations and delusions had a slightly higher number of arrests for violent crime, but not significantly so. These findings held even after controlling for prior violence and age. The findings do not support the stereotype that mentally ill criminals invariably commit violent crimes after they are released. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Violence and psychiatric disorders: results from an epidemiological study of young adults in Israel

This paper investigates the association between various psychiatric disorders and violent behavior using data from a community-based epidemiological study of young adults in Israel (N = 2678). Self-reports of recent fighting and weapon use were elevated among respondents diagnosed with psychotic or bipolar disorders but not among those diagnosed with non-psychotic depression, generalized anxiety disorder or phobias compared to respondents without these disorders. Violence was measured using the Psychiatric Epidemiology Research Interview; psychiatric disorders were diagnosed using a modified version of the Schedule for Affective Disorders and Schizophrenia. The analyses controlled for lifetime substance abuse, antisocial personality disorder and demographic characteristics, thereby extending support for a causal connection between some types of psychiatric disorders and violence. The association between disorder and violence was stronger among respondents with less education, indicating the potentially important role of social and cultural contexts in moderating the association between mental illness and violence.     

Violent thoughts and violent behavior following hospitalization for mental disorder.

Using a standardized schedule of questions, this study examined (a) the prevalence of self-report of violent thoughts by patients hospitalized for mental disorders compared with nonpatients, (b) the persistence of violent thoughts after discharge, and (c) the relation between patients' violent thoughts while hospitalized and violent acts within 20 weeks after hospital discharge. About 1/3 of the patients reported thoughts of violence while hospitalized, more than twice the proportion found among nonpatients. Reporting violent thoughts in hospital was significantly related to engaging in violent acts within 20 weeks after discharge for non-White patients, patients without major mental disorder but with substance abuse diagnoses, patients with high symptom severity, and patients whose reports of violent thoughts persisted after discharge. Reporting violent thoughts was significantly related to measures of psychopathy, anger, and impulsiveness. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychopathy in instrumental and reactive violent offenders.

Can violent offenders who commit acts of instrumental aggression for goal-oriented purposes such as robbery be distinguished from those who commit acts of reactive (or hostile) aggression in response to provocation? Because violent offenders often have a history of both instrumental and reactive aggression, this study distinguished between offenders with a history of at least 1 instrumental violent offense and offenders with a history of reactive violent offenses. Two studies tested the hypothesis that instrumental offenders would score higher than reactive offenders and nonviolent offenders on R. D. Hare's (1991) Psychopathy Checklist. The first study sample consisted of 106 violent and nonviolent offenders recruited from a medium-security correctional facility. The second study sample consisted of 50 violent offenders referred for pretrial forensic evaluation. In both samples, instrumental offenders could be reliably distinguished from reactive offenders on the basis of violent crime behavior and level of psychopathy. Group differences could not be attributed to participant age, race, length of incarceration, or extent of prior criminal record. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The treatment of mentally disordered offenders.

However narrowly defined, mentally disordered offenders (MDOs) are heterogeneous in demographics, diagnoses, offense characteristics, risk, and clinical needs. Treatment planning for MDOs should begin with an assessment of risk of future violent behavior in the community and risk of violence toward self or others inside an institution. Purposes of treatment among MDOs include treatments both to reduce risk of future violence and to alleviate the mental disorder. Relevant outcome measures include criminal and violent behavior, psychiatric symptomatology, admission to correctional or psychiatric facility, and quality of life. Clinical problems include aggression and problems of institutional management, criminal propensity, life skills deficits, substance abuse, active psychotic symptoms, social withdrawal, and depression. Because evidence relating them to risk of future violence is highest for the first 4 problems, it is argued that inpatient treatments should especially target them. Whenever risk levels and legal circumstances permit, community treatment is to be preferred. Sex offenders are discussed as a group for whom specialized services are indicated.… (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Laryngeal cancer: quality-of-life and cost-effectiveness

The purpose of this paper is to review the current literature in relation to mental illness and criminal behaviour. The material presented for discussion was selected from forensic and general psychiatric literature. However, a number of important publications, policy documents and independent reports were used to explore the debate surrounding this subject. Contemporary studies of prison populations in the UK and abroad illustrated the difficulty in relating mental illness to crime. Papers presenting research in the UK revealed important implications for mental health policy and the way in which the penal system deals with mentally disordered offenders. The literature reviewed provided arguments for and against an association between mental illness and criminal behaviour. Methodological problems associated with criminological and psychiatric research were addressed in relation to the exploration of whether people suffering from a mental illness are more dangerous or violent than other people. Research papers focusing on public reaction to mentally ill people living in the community provided important considerations when addressing mental illness and criminal behaviour in the context of care in the community policy. This paper will be of interest to a broad range of mental health professionals, particularly those working with individuals who have a history of mental illness and violent behaviour, or mental health professionals working with mentally disordered offenders.     

Endovascular treatment of internal iliac artery aneurysms

BACKGROUND: Homeless people with mental illness have relatively high rates of human immunodeficiency virus, comorbid antisocial personality disorder, and may be homeless more frequently and for greater lengths of time. All of these factors may increase the risk of tuberculosis. METHODS: Our study was done to ascertain if homeless men with psychotic disorders are at an increased risk for tuberculosis infection. One hundred fifty homeless men were interviewed and given purified protein derivatives (PPDs) at a downtown shelter in New Orleans, Louisiana, during a 3-month period. RESULTS: The findings show a strong relationship between psychotic disorders and positive PPDs, with a relative risk of 4.48. CONCLUSIONS: Homelessness and mental illness present barriers to seeking and completing treatment for medical illnesses such as tuberculosis. Use of services may be low even when available; therefore, homeless men with psychotic disorders may be serving as a reservoir for tuberculosis.     

The prevalence of allergic rhinitis and nasal symptoms in Nottingham

An overview of the most important older and newer results regarding the relationship between violent and criminal behavior on the one hand and schizophrenic illness on the other hand is presented. Four different methods are available to study this relationship: (i) study of the prevalence of mental illness in criminal/violent populations; (ii) study of criminality/violence rate in samples of psychiatric patients; (iii) study of criminality/violence in community samples comparing mental patients with non-patient community residents; and (iv) study of criminality/violence in birth cohorts prospectively. All these methods have been used; but samples composed of schizophrenic patients exclusively were only exceptionally studied. The results indicate that there is a modest but significant relationship between schizophrenia and violence and crime which persists even after controlling for demographic and socio-economic variables. The probability of schizophrenic patients to be criminal or violent depends on the acuity of their illness and is increased by their use of psychoactive substances. Generally, however, violent and criminal acts directly attributable to mental illness account only for a very small proportion of such acts in the society.     

Sexually violent predators in the courtroom: Science on trial.

Adjudication of sexually violent predator commitment laws places demands on science. In the current article, the authors discuss the determination of mental abnormality and its reliance on medical nosological systems. Second, the authors examine the determination of current risk by reviewing three common concerns: (a) mechanistic estimations of risk, (b) mitigation of risk as a function of age, and (c) estimation of contemporaneous (dynamic) risk. The authors focus specifically on determinations of risk posed by the nexus of mental abnormality with prior history of sexually violent acts. Third, the article examines relevant, though sometimes nonstatutory, considerations, namely, the standards and expectations for treatment provided in high-security civil commitment programs. Potentially important dynamic or time-varying factors that may mitigate risk, such as offender age and treatment, are considered. Recommendations to promote "good science" and to avoid "bad science" are included with respect to determinations of mental abnormality, risk of reoffending, and treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Occupational allergic disease in cereal workers by stored grain pests

This review paper explored the concepts of risk assessment and management in relation to 'serious' violence by individuals with mental disorder. The paper highlighted the political context in which concern over serious violence by those with mental disorder is increasing. Government guidance on risk assessment was considered and identified as having an actuarial bias. Correlational studies, which provide actuarial indicators of risk, were explored and a picture was developed that demonstrated the difficulty of determining risk of violence to others simply on the basis of psychiatric symptomatology. The literature led to a conclusion that risk assessment for violence is an inexact science, and that actuarial indicators need to be supported by structured thorough clinical investigation. Legal concerns around the assessment and management of risk were also explored. The Health and Safety Executive model for risk management was explored in relation to the findings of the risk-assessment literature and the recommendations of reports into serious violent incidents. The model was shown to have potential utility in providing a legally sound framework for the assessment and management of risk of violence in mental disorder.     

Prevalence of mental disorder in remand prisoners: consecutive case study

OBJECTIVE: To define the prevalence of mental disorder and need for psychiatric treatment in new remand prisoners and to determine to what extent these are recognised and addressed in prison. DESIGN: Study of consecutive male remand prisoners at reception using a semistructured psychiatric interview. SETTING: Large remand prison for men (HMP Durham). SUBJECTS: 669 men aged 21 years and over on remand, awaiting trial. MAIN OUTCOME MEASURES: Prevalence of mental disorder at reception, prisoners need for psychiatric treatment, identification of mental disorder by prison reception screening, and numbers placed appropriately in the prison hospital. RESULTS: 148 (26%) men had one or more current mental disorders (excluding substance misuse) including 24 who were acutely psychotic. The prison reception screening identified 34 of the men with mental disorder and six of those with acute psychosis. 168 men required psychiatric treatment, 50 of whom required urgent intervention; 16 required immediate transfer to psychiatric hospital. Of these 50, 17 were placed on the hospital wing because of mental disorder recognised at prison screening. CONCLUSION: Not only is the prevalence of mental disorder, in particular severe mental illness, high in this population, but the numbers identified at reception are low and subsequent management in prison is poor.     

Mental health consultant to law enforcement: Secret Service development of a Mental Health Liaison Program

The Mental Health Liaison Program developed and used by the Secret Service is presented as a model for comprehensive, multidimensional interactions between law enforcement and mental health systems, with particular focus on assessing and preventing violent behavior. The structure of the program pairs consultants--psychologists and psychiatrists--with Secret Service field offices to provide (a) consultation regarding risk assessment and case management of individuals who threaten or display inappropriate interest in the President or other protectees; (b) training for agents on risk assessment, mental illness, and mental health care issues; and (c) liaison activities between the Secret Service and the mental health community. Practical benefits to the Secret Service are discussed to encourage more systematic use of broad based psychological and psychiatric consultation to law enforcement, with a goal of enhanced intersystem communication and collaboration. The need for program evaluation and outcome research is discussed in the context of applying the model to improve other mental health and law enforcement systems interactions.     

Homicide in Capgras'' syndrome

A case of Capgras' syndrome associated with homicidal behavior is reported. The psychodynamic implications are discussed. Capgras' syndrome could lie at the base of aggressive and homicidal acts directed towards family members during psychotic breakdown. Capgras' syndrome should always be evaluated in order to prevent violent acts, understand the psychologic characteristics of the patient and undertake the corresponding treatment.     

Physical attractiveness and self-perception of mental disorder.

Prior research has reported a relation between physical attractiveness and severity of mental disorder, with less attractive people being more maladjusted. However, because these two variables have been measured simultaneously, it has not been possible to separate cause from effect. To clarify this question, in this study we first measured physical attractiveness, social competence, and perceived risk of developing a mental disorder in 280 college women. Seven months later, we measured the subjects' self-perception of having a mental disorder. Women who were more attractive were higher in social competence and lower in perceived risk of mental disorder. More attractive women were also lower in self-perception of mental disorder 7 months later. This relation between attractiveness and self-perception of mental disorder remained significant even after controlling for the Time 1 measures (social competence, perceived risk of mental disorder, and age). The implications of these findings for the hypothesized role of attractiveness in the determination of adjustment are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Longitudinal changes in cortisol secretion and conversion to psychosis in at-risk youth.

Elevations in hypothalamic–pituitary–adrenal (HPA) axis activity have been implicated in the origins and exacerbation of mental disorders. Several lines of investigation suggest HPA activity, indexed by increased cortisol, is elevated in patients with schizophrenia and other psychotic disorders. This study examined the relation of cortisol levels and longitudinal changes with psychotic outcomes in at-risk adolescents. Participants were 56 adolescents who met risk criteria for psychosis, namely, schizotypal personality disorder (n = 5), prodromal symptom criteria based on the Structured Interview for Prodromal Symptoms (n = 17), or both (n = 34). Of these, 14 subsequently met DSM–IV criteria for an Axis I psychotic disorder (schizophrenia, schizoaffective disorder, or mood disorder with psychotic features). Participants were assessed at baseline and then followed longitudinally. Salivary cortisol was sampled multiple times at initial assessment, interim follow-up, and 1-year follow-up. Area under the curve (AUC) was computed from the repeated cortisol measures. The findings indicate that at-risk subjects who subsequently developed psychosis showed significantly higher cortisol at the first follow-up, a trend at the 1-year follow-up, and a significantly larger AUC when compared to those who did not convert. A similar pattern of group differences emerged from analyses excluding those who may have converted prior to the 1-year follow-up. These findings converge with previous reports on HPA activity in psychosis, as well as theoretical assumptions concerning the effects of cortisol elevations on brain systems involved in psychotic symptoms. Future research with larger samples is needed to confirm and extend these results. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The Prediction of Violence and Homicide in Young Men.

In this prospective study, the authors predicted violence and homicide in 3 representative school samples (N = 1,517). Participants were part of a longitudinal, multiple cohort study on the development of delinquency in boys from late childhood to early adulthood in Pittsburgh, Pennsylvania. Thirty-three participants were convicted of homicide, 193 participants were convicted of serious violence, whereas another 498 participants self-reported serious violence. Predictors of violence included risk factors in the domains of child, family, school, and demographic characteristics. Boys with 4 or more violence risk factors were 6 times more likely to later commit violence in comparison with boys with fewer than 4 risk factors (odds ratio [OR] = 6.05). A subset of risk factors related to violence also predicted homicide among violent offenders. Boys with 4 or more risk factors for homicide were 14 times more likely to later commit homicide than violent individuals with fewer than 4 risk factors (OR = 14.48). Implications for the prevention of violence and homicide are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychiatric illness in mentally retarded adolescents: clinical features

Attempts have been made to establish objective diagnostic criteria for psychiatric disorders in persons with mental retardation. This paper describes the clinical features of the most important psychiatric disorders in mentally retarded adolescents: mood disorders, psychotic disorders, severe behavioral disorders, personality disorders, anxiety disorders, and attention deficit disorder with hyperactivity. The impact of mental retardation on personality development is confirmed by the high psychopathological vulnerability of the mentally retarded. All types of mental disorders can be observed, with an incidence estimated to be at least three or four times higher than in the general population. Adolescence is a particularly important phase for the mentally retarded, since adolescent turmoil can increase the risk of psychopathology.