As mentioned previously, the recent National Institute of Mental Health's CATIE study suggested a link between schizophrenia and violence. That conclusion generated a lot of controversy from folks who assert that there is no link between mental illness and violence, touting the frequent mantra that those with mental illness are no more likely to become violent than the general population. Indeed, we should be careful not to needlessly contribute to the enduring stigma that burdens those with mental illness. Nonetheless, we shouldn't ignore the link between mental illness and crime simply because it makes some people uncomfortable or is at odds with the vested rhetoric of political correctness. Several recent studies in the journal Psychiatric Services shed some new light on the subject and are worth a few comments.
The first article, The MacArthur Violence Risk Assessment Study Revisited: Two Views Ten Years After Its Initial Publication, presents a debate between E. Fuller Torrey and Johnathan Stanley of the Treatment Advocacy Center and the original authors of the the seminal 1998 article, Violence by People Discharged From Acute Psychiatric Inpatient Facilities and by Others in the Same Neighborhoods published in the Archives of General Psychiatry. This study reported "there was no significant difference between the prevalence of violence by patients without symptoms of substance abuse and the prevalence of violence by others living in the same neighborhoods who were also without symptoms of substance abuse." This study has been widely cited by those who claim there is no link between mental illness and violence. Yet, as the commentary in Psychiatric Services suggests, much of this rhetoric falls short once a critical lens is placed upon the MacArthur study. As authors Torrey and Stanley rightly claim:
The prevalence of violent behavior among the discharged patients in the original MacArthur Study was, in fact, high. The details of the violent acts committed by the discharged patients were made available in publications after the initial report. Among the 951 discharged patients followed up after discharge from the hospital, 262 (27.5%) “committed at least one act of violence while in the community” during an average follow-up period of 41 weeks.
Torrey and Stanley also raise a number of other points about the MacArthur study which cast doubt about the popular interpretations of that study, including the astounding fact that the comparison group for the MacArthur study consisted almost entirely of people selected from neighborhoods with the highest crime rates. Thus, the comparison group had an inflated violence rate when compared to the general population, which essentially minimized the rate of violence among those with mental illness in the study. Despite these facts, Torrey and Stanley also wisely suggest that the upshot of the MacArthur and similar studies is that the risk factors for violence among those with mental illness are more similar to the general population rather than any unique facet within mental illnesses. That is, alcohol and drug abuse seems to account for a large amount of the risk for violence among those with mental illness just like everyone else. The elephant in the room, however, is the exceedingly high rate of substance abuse among those with severe mental illnesses.
The second study, Perpetration of Violence, Violent Victimization, and Severe Mental Illness: Balancing Public Health Concerns reviewed all studies in the United States published since 1990 which examined the prevalence of violence and mental illness. It found a prevalence rate among psychiatric outpatients between 2-13% over follow-up periods ranging from 6 months to 3 years. It also found that those with mental illnesses are often the victims of violence as well (20% to 34%).
The third study, Risk of Incarceration Between Cohorts of Veterans With and Without Mental Illness Discharged From Inpatient Units, compared the rates of arrest between veterans with and without mental illness in Connecticut from 1993-1997 (n=36,385) (disclaimer: the author of this post is the lead author). There were two particularly noteworthy findings of this study. First, during the study period the overall rate of incarceration among veterans with mental illnesses declined. This happened during the same period when over 80% of the inpatient psychiatric beds in the VA Connecticut system were closed. It also occurred during a time when incarceration rates among the general population for Connecticut rose substantially. Second, the greatest risk factor for incarceration among the sample was substance abuse as this table indicates:
These studies confirm what other studies have found, which is a strong link between criminality and substance abuse. As a recent commentary noted, it is increasingly clear that this link extends to violence among those with mental illnesses as well. Yet as author Friedman aptly concluded:
The challenge for medical practitioners is to remain aware that some of their psychiatric patients do in fact pose a small risk of violence, while not losing sight of the larger perspective — that most people who are violent are not mentally ill, and most people who are mentally ill are not violent.
Putting all of the rhetoric aside, the risk of violence and crime among those with mental illness who abuse alcohol and drugs is a serious risk in need of candor within the academic and popular realms of debate. It isn't foolish to observe the sadly obvious:
Leave a comment