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.     

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)     

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.     

Criminalizing mental disorder: The comparative arrest rate of the mentally ill.

Notes that there has been a great deal of speculation that mentally ill persons are being processed through the criminal justice system rather than the mental health system. To date, this thesis has been based more on intuition than on empirical research. Data from a study of 1,382 police–citizen encounters are presented that suggest that the mentally ill are indeed being criminalized. Specifically, it was found that, for similar offenses, mentally disordered citizens had a significantly greater chance of being arrested than non-mentally-disordered persons. This finding has public policy implications for the basic tenets of the community mental health movement, as well as for optimal functioning of the criminal justice system. Several public policy modifications are suggested. (56 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The prediction of criminal and violent recidivism among mentally disordered offenders: A meta-analysis.

A meta-analysis was conducted to examine whether the predictors of recidivism for mentally disordered offenders are different from the predictors for nondisordered offenders. Effect sizes were calculated for 35 predictors of general recidivism and 27 predictors of violent recidivism drawn from 64 unique samples. The results showed that the major predictors of recidivism were the same for mentally disordered offenders as for nondisordered offenders. Criminal history variables were the best predictors, and clinical variables showed the smallest effect sizes. The findings suggest that the risk assessment of mentally disordered offenders can be enhanced with more attention to the social psychological criminological literature and less reliance on models of psychopathology. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Characteristics of the populations at the Robert Giffard Psychiatric Hospital Center: people with intellectual deficiencies and people with mental disorders

Within the context of the general reorganization of health care and social services in Québec, the present study aims at describing physical and mental characteristics of persons with mental health problems and who are mentally retarded still hospitalized in a psychiatric hospital. In the first study, 146 mentally retarded persons of which 74 formed the community group and 72 the institutionalized group. The results indicate that 84% of the mentally retarded persons still hospitalized manifested sufficiently important needs on the three measured variables (health, deficits and behaviors) to justify intensive care in a structured environment. The Behavior variable is more important in deciding the integration of these people in the community. As most of these persons have a higher level of disabilities and more behavior manifestations, the support required for these people in the community and persons delivering services will have to be more structured and intensive in nature. In the second study, 928 psychiatric patients still hospitalized were studied on the variables, age, sex, diagnostics and the global scores (physical and mental) of the level of care survey and functional autonomy. The results show that the proportion of women in the age group 35 and older were progressively increasing in relation to the men. The primary diagnostic reported more frequently was schizophrenia in 70% of cases. In the evaluation of physical care of the people still hospitalized, age becomes an important factor. Generally speaking, the population within the institution is aging and women are progressively growing in number. As these people expressed more physical ailments and a decline in basic autonomy, more structured and specialized care and support will be required to respond to their needs.     

The role of histamine in platelet aggregation by physiological and immunological stimuli

This paper reviews the current state of the debate on the relationship between mental disorder and violent behaviour. Starting from the discussion of methodological approaches to assessing a possible association, the most important studies carried out on the issue in recent years are discussed. Their results concur in supporting the assumption that there is a moderate but reliable association between mental disorder and violence. However, this does not imply that people with mental illness are generally more likely to commit violent acts than members of the general population. An elevated risk of violent behaviour is only evident for specific psychiatric diagnoses and for particular symptom constellations. For schizophrenia and other psychotic disorders, a significant increase in the likelihood to commit violent acts is reported. Substance use disorder and antisocial personality disorder, however, represent a markedly higher risk for violent behaviour. The article further discusses possible determinant of violent behaviour such as psychotic symptoms and comorbidity with substance abuse, and considers who is at particular risk of becoming a target of violent acts.     

Interactions between mental health and law enforcement systems: problems and prospects for cooperation

This article examines the challenges posed by system specialization, as illustrated by the difficulties of coordinating the roles of the mental health and law enforcement agencies working with people with severe mental illness. Dealing with the needs of clients in one system when they are most appropriately served by the other may make both law enforcement and mental health systems appear ineffective and inefficient. This could increase the incidence of disorderly or violent behavior, which forments the myth that the seriously mentally ill are inherently dangerous. Despite the evident need to manage these issues, conventional methods of coordinating services have failed. This article concludes by developing a contracting model that creates more appropriate incentives for the two systems and bridges the gap between them.     

An integrative ideology to guide community-based multidisciplinary care of severely mentally ill patients

Most practitioners working in community support settings understand the need to provide a comprehensive array of well-coordinated services to individuals with severe mental disabilities. However, a lack of consensus about the conceptual basis of mental health care, especially between advocates of psychosocial rehabilitation and psychiatric practitioners who favor a more medically oriented approach, has hindered efforts to optimize the effectiveness of the multidisciplinary teams found in most community support programs. The authors articulate 18 basic assumptions that have been helpful in their clinical practice in building an integrative ideology among professionals with disparate training and orientations. The assumptions attempt to balance the reality of psychiatric disorders with a fundamental interest in maintaining the autonomy and dignity of people with severe mental disorders.     

The system that cannot say no.

In response to a paper by L. A. Teplin (see record 1985-12217-001) on how the criminal justice system has dealt with deinstitutionalized psychiatric patients, a perspective on how the corrections system attempts to cope with the increasing influx of mentally disordered offenders is presented. Issues related to transfer, in-house care programs, and the quality-of-care problem are examined. (1 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Clinical psychologist in the vanguard: Current attitudes toward mental illness.

To determine the current degree of acceptance of an antimedical approach to mental illness, a survey was conducted of attitudes toward mental illness among various mental health professionals (20 psychiatrists, 23 psychiatric nurses, 16 psychologists, and 25 social workers) and mental patients (41 outpatients with a history of psychiatric hospitalization and 20 outpatients with no similar history) in a community mental health center. Responding to 6 statements reflecting attitudes toward the traditional medical model, clinical psychologists showed greater acceptance of the antimedical paradigm than did psychiatrists, psychiatric social workers, psychiatric nurses, and psychiatric outpatients. Several explanations are offered as to why clinical psychologists appear to be in the vanguard of those adopting a critical, antimedical stance within the clinical arena. (32 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Dexamethasone concentration in vitreous and serum after oral administration

OBJECTIVE: To assess the outcomes of changes in mental health policy introduced in Italy in 1978. METHODS: Data on psychiatric services, before and after the policy change, are presented. Effects of change are evaluated through indicators related to four issues: transfer of care, criminalisation of the mentally ill, suicides, and homelessness. RESULTS: Admissions of new patients to mental hospitals have been stopped and the size of the mental hospital population is now very low (26 per 100,000 population). Psychiatric care has been shifted to community services including general hospital psychiatric units. There has been an overall reduction of psychiatric hospitalisation. However, the provision of residential facilities is inadequate and community services are unevenly distributed across the country. Few negative effects of changing patterns of care have been reported, although the low quality of data limits the validity of such a conclusion. Outcome of care in areas where the full range of community services is available has been rated as satisfactory. CONCLUSIONS: Although care of the mentally ill has been shifted to community services, we lack hard data on the social and clinical outcome of community care at the nation-wide level. Long-term monitoring and evaluation of community services is a high priority in Italy.     

Mental health needs of the chronically mentally ill elderly.

The treatment histories and current social, financial, and clinical status of 111 chronically mentally ill (CMI) persons over the age of 60 were examined. Information was obtained from Ss, family, mental health records, and mental health professionals familiar with Ss. Psychiatric symptoms were observed in 74% of Ss. Many Ss experienced long periods without acute episodes of illness. Recurring episodes eventually appeared in most Ss, however, and ongoing deficits in daily functioning and social contacts were prototypical. Two thirds of the Ss were living in the community, relying heavily on family contacts; the rest lived primarily in nursing homes (23.4%) or psychiatric hospitals (7.2%). Social support was the best predictor of level of functioning. Findings suggest that failure of CMI elderly to use mental health services is not due to lack of need. Mental health services currently do not appear to be meeting the needs of this population. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Saleem A. Shah (1931–1992): Obituary.

Memorializes S. A. Shah, whose contributions to the field of law and mental health included his commitment to the goal of achieving fair and equitable treatment for mentally disordered offenders and other persons whose mental status was at issue before the law. He also established law and mental health studies as a formal program priority at the National Institute of Mental Health. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The criminalization of the mentally ill: Speculation in search of data.

Examines the evidence for the speculation that mentally ill persons who would previously have been treated within mental hospitals are now processed through the criminal justice system and constitute an ever-increasing proportion of the jail population. Three factors underlie this speculation: the increase in mentally ill persons residing in the community, police handling of the mentally ill, and evidence that persons thought to be dangerous are among the most unwanted clients of mental health agencies. Three types of research are explored: archival studies, investigations of police decision making, and studies of the prevalence of mental disorder among jail detainees. It is concluded that the research literature, albeit methodologically flawed, offers at least modest support for the contention that the mentally ill are being processed through the criminal justice system. (81 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Who cares? Pathways to psychiatric care for young people experiencing a first episode of psychosis

OBJECTIVE: The authors reviewed the literature to better understand pathways to psychiatric care among young persons experiencing a first episode of psychosis. Because no discrete body of literature exists about how young people with psychotic illness gain access to psychiatric services, the authors examined three related areas: illness recognition, help-seeking, and referral pathways. METHODS: Automated and manual searches of primarily medical and psychological sources from 1977 to 1995 were conducted. RESULTS: The review found evidence of delay in obtaining early treatment among young people with an emerging psychosis, although comparisons between studies are difficult. Early psychiatric intervention is believed to significantly aid recovery and is an increasingly important clinical issue. Recognizing psychiatric illness is problematic for professionals and nonprofessionals. CONCLUSIONS: Understanding of help seeking by patients experiencing a first psychotic episode and of their referral pathways is limited. Taken together, studies suggest factors affecting access to treatment but provide neither sufficient empirical information nor an adequate conceptual framework to better target secondary prevention strategies. Formulation of a pathways-to-care model appears to offer a useful way of understanding mental health care use. Exploration of consumer experiences would enrich the model. Strategies to reduce treatment delay could then be developed and evaluated. Increased consumer involvement might help ensure that services are better tailored to patients' needs.     

Arrest trajectories of adult offenders with a serious mental illness.

We examined patterns and correlates of arrest/re-arrests among offenders with a serious mental illness over a 4-year period. County criminal justice records and health and social service datasets were used to identify and describe inmates jailed in Pinellas County, Florida, between 7/03 and 6/04. A total of 3,769 participants (10.1% of arrestees) had a serious mental illness. Participants averaged 4.6 arrests (SD = 3.9, median = 4) and 150.6 days in jail (SD = 175.0, median = 90).Working from the trajectories of offending theory and literature we used latent class growth analysis to identify three classes of offenders with consistent numbers of arrests over a 4-year period and nearly parallel arrest trajectories; a sporadic arrest class (n = 469) with minimal arrests, a low arrest chronic class (n = 3,090, about one arrest/year); and a high arrest chronic class (n = 210, about four arrests/year). Analysis of arrests by age group within each of the classes suggested that for the low and high arrest chronic classes arrest rates persist throughout adult life. In multinomial logistic regression, homelessness, a co-occurring substance abuse diagnosis, fewer mental health outpatient service contacts and more mental health emergency room/inpatient contacts were associated with being in a class with more arrests. Arrests among offenders with a serious mental illness appear to be unusually high, to be firmly established in late adolescence and to persist over time. Successful strategies to reduce the arrest rates of this population must address the needs of these offenders early in their criminal careers. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Awards for distinguished contribution to research in psychology: Linda A. Teplin.

The Board for the Advancement of Psychology in the Public Interest confers the Award for Distinguished Contribution to Research in Public Policy upon a psychologist who has made a distinguished empirical and/or theoretical contribution to research in public policy, either through a single extraordinary achievement or a lifetime of work. This contribution might include research leading others to view specific national policies differently, research demonstrating the importance of the application of psychological methods and theory to public policy, or research clarifying the ways scientific knowledge of human behavior informs public policy. One of the two winners of this award is Linda A. Teplin. She pioneered the introduction of rigorous psychological field methodologies into real-world criminal justice contexts. Her widely cited studies of how police interact with citizens they perceive as mentally disordered have become the gold standard for research on police behavior. Her more recent but equally definitive work on the prevalence of mental disorder among urban jail populations has firmly established the extraordinary need for mental health services within these community institutions. Her creation of an empirically derived scale to facilitate the referral of inmates for psychological evaluation has the potential to transform jail mental health services in the United States. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Criminal thinking as a mediator of the mental illness–prison violence relationship: A path analytic study and causal mediation analysis.

Although mental illness and violence correlate, it has been speculated that this relationship is mediated by a series of third variables. The current study examined the possibility that the relationship between mental illness and prison violence is mediated by criminal thinking. General criminal thinking, as measured by the General Criminal Thinking (GCT) score of the Psychological Inventory of Criminal Thinking Styles (PICTS; Walters, 1995), was tested as a possible mediator of the mental illness–prison violence relationship. Using a prospective design and path analytic statistical technique, it was determined that general criminal thinking served as a partial mediator of the mental illness-institutional violence nexus in a sample of 2,487 male prison inmates. Causal mediation analysis also documented the presence of a small but statistically significant mediating role for general criminal thinking in this study. The implications of these results for understanding, predicting, and managing violent behavior in severely mentally ill inmates are discussed. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Fear, prejudice, and neglect: Discrimination against mentally disabled persons.

Historically, the law has directly discriminated against mentally disabled persons and has failed to protect them from discrimination by private parties. Despite the arguments of the American Psychological Association and other mental health organizations, the Supreme Court has refused to consider state-sanctioned discrimination on the basis of mental disability as requiring a higher level of judicial scrutiny to ensure that it is related to important governmental objectives. Without such scrutiny, policy decisions based on prejudice and fear may jeopardize fair and humane treatment of mentally disabled persons in community and institutional settings. Such inadequate legal protection for mentally disabled persons heightens the significance of the professional responsibility of psychologists and other mental health professionals to promote respect for the personal autonomy of their clients and to strive to preserve their clients' constitutional rights of due process and equal protection under the law. To further legislative advocacy efforts on behalf of mentally disabled persons, an overview of existing federal antidiscrimination statutes is provided, along with a discussion of more recent legislation granting mentally disabled persons affirmative rights in a variety of contexts. (PsycINFO Database Record (c) 2010 APA, all rights reserved)