By Rebecca Syed, King’s College London.
A violent attack by someone who is mentally ill quickly grabs the headlines. And it’s usually implied that mental illnesses are a preventable cause of violent crime. Tackle that and we can all sleep safer in our beds.
But by pressuring mental health services to focus on the risk of violence we are in danger of actually increasing it.
Most of the debate around risk and offending has centred around schizophrenia – the bread and butter of community psychiatry. But what is the evidence relating to the risk of violence in those diagnosed with schizophrenia?
It’s tricky because schizophrenia varies so much in character and severity. And other factors known to have an association with violent crime, like migration and social disadvantage, are often also implicated as a part of the cause or consequence of schizophrenia.
To assess the risk of someone with schizophrenia attacking others, we’re basically trying to work out the risk of a rare event happening in a bunch of people with a mixed bag of symptoms with the “schizophrenia” label – and with multiple other factors confounding and perpetuating the issue. No wonder it’s nigh on impossible to work out the risk from just the schizophrenia.
Other factors in play
Researchers put different emphasis on the importance of these other factors. This might explain the wide variation in the figures for how much more likely violence is in someone with schizophrenia.
The largest study to date (Fazel, 2009), conducted in Sweden, compared more than 8000 people with schizophrenia with control groups using hospital and criminal records. They found that much of the increased rate of violence in those with schizophrenia was confined to those who also abused drugs.
Controlling for other factors, those with a diagnosis of schizophrenia who did not abuse drugs were only 1.2 times more likely to have committed at least one violent offence than control subjects. But even for those with a diagnosis of schizophrenia who did abuse drugs, the comparison lessened when the researchers considered early environment and genetics – they were only 1.8 times more likely to have committed at least one violent crime than their siblings (who didn’t have schizophrenia).
But a recent Australian study (Short, 2013) showed that people with schizophrenia – even without substance abuse – were twice as likely as control subjects to have a violent conviction.
Most researchers recognise that there is an increase in violent offending in those diagnosed with schizophrenia. But the studies don’t tell us how much violent offending is actually caused by the mental disorder itself.
And we tend to forget about how uncommon it is to have these kinds of incidents (though shouty headlines can make us think otherwise). Even if it could be proved that the disorder actually caused an increased rate of violence, completely taking all of those with major mental disorders out of society would only reduce violent crime by about 5%) – less than for drugs and alcohol.
Is our obsession with risk making it worse?
So what worries me is the interpretation and outcomes of these findings and their adoption into policy, legislation and clinical practice.
The real danger here is that the focus is on risk, and decisions based only on that risk at the expense of the illness itself, could even increase that risk.
The main problem is that we’re not actually very good at predicting violent events. This isn’t because mental health professionals are rubbish but mainly because they’re so rare in the populations we’re looking at.
A concept that just doesn’t seem to be that well understood, even among doctors, is that the predictive ability of any risk assessment depends on the rate of the event in the population we’re looking at. The lower the rate, the less able the assessment is to correctly predict it. If something happened frequently, it would be easier to predict.
Although the rate of violence may be slightly higher in those with schizophrenia than Jo Public the absolute rate of violence in those who suffer from schizophrenia is still very low – too low to predict with any accuracy.
Our worst fear?
Let’s look at the worst case scenario – murder.
If we use the MacArthur instrument – one of the well evaluated tools for measuring the risk of violence – to classify people as a high or low-risk of committing murder then, as Australian psychiatrist Christopher Ryan put it:
4117 patients would have to be detained or otherwise managed for a year in a homicide-proof fashion to try to prevent just one of those patients committing a homicide. And yet one in every 22,421 patients assessed to be ‘low-risk’ would commit a homicide in that period.
Most people who suffer from schizophrenia would correctly be classified as low risk. Because of this, they would have resources diverted away from them despite suffering from a debilitating but treatable condition. And a very few of those classified as low risk would actually go on to commit a violent offence.
We currently have different legislation for those with mental health problems. It is hard to imagine any other group of people being subject to different laws based on a higher statistical rate of violence. Men are more likely to be violent than women but aren’t subject to legislation that allows us to more easily detain them against their will.
Not that we should just shrug our shoulders and say that risk just isn’t our thing. A comprehensive assessment that includes a risk component should allow people to make informed decisions about their treatment, based on their capacity to do so (which, incidentally, is something we are good at assessing).
Decisions should rely on the characteristics of the illness and evidence for treatment, not just the enforcement of short-term and inadequate interventions as a nod to risk at the expense of treating the illness itself.
We know there is a higher rate of violence in those who’ve developed schizophrenia before they even seek help from services. I’m pretty sure that if I was suffering from schizophrenia I would be more likely to go to services that offered help for my illness rather than those seen as punitive and risk-obsessed.
Sadly, the over-emphasis on risk of violence is a grave disservice to many suffering from a debilitating but treatable illness.
Rebecca Syed does not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article, and has no relevant affiliations.
This article was originally published at The Conversation.
Read the original article.
Short T, Thomas S, Mullen P, Ogloff JR. Comparing violence in schizophrenia patients with and without comorbid substance-use disorders to community controls. Acta Psychiatr Scand. 2013 Feb 4. doi: 10.1111/acps.12066. [Epub ahead of print] [PubMed abstract]
Fazel S, Långström N, Hjern A, Grann M, Lichtenstein P. Schizophrenia, Substance Abuse, and Violent Crime. JAMA.2009;301(19):2016-2023. doi:10.1001/jama.2009.675.
@Mental_Elf when i was psychiatric ward 32.a you lady had voices in her mind,i offen got her a cuppa tea, on leaving she gave me a huge HUG
@Mental_Elf I have seen it happen. @hermitsholiday
Thanks to @ConversationUK for today’s guest blog on the risk of violence in ppl diagnosed with schizophrenia http://t.co/BXlqhSoaK4
Why is there a wide variation in reported figures for how likely violence is in someone with schizophrenia? http://t.co/BXlqhSoaK4
@Mental_Elf Probably no standardised universal survey undertaken linking law enf & psychs? Plus diagnostic var’ns. & verbal abuse not inc
The absolute rate of #violence in those with #schizophrenia is very low – too low to accurately predict http://t.co/BXlqhSoaK4
Over-emphasis on the risk of violence is a grave disservice to those suffering from #schizophrenia http://t.co/BXlqhSoaK4
@Mental_Elf ENTIRELY agree. Much more of a risk of danger to the sufferer rather than from the sufferer but then that makes poorer headlines
Are you really at risk of attack by someone with schizophrenia? – The Mental Elf http://t.co/Y9BuEFNFZ6 Good reading
Are you really at risk of attack by someone with schizophrenia? http://t.co/F8vuzAHSBK via @sharethis
In case you missed it earlier: Are you really at risk of attack by someone with schizophrenia? http://t.co/BXlqhSoaK4
@Mental_Elf Very useful information on the real risks of violence and schizophrenia especially as I teach about it.
no you are not
Are you really at risk of attack by #schizophrenia? http://t.co/vQknAJ2kwz @Mental_Elf #MentalHealth #violence http://t.co/JgH2tWOfxs
Top story: Are you really at risk of attack by someone with schizophrenia? – Th… http://t.co/lcGPy3lH2J, see more http://t.co/erffJ2Ubp5
RT @Mental_Elf Are you really at risk of attack by someone with #schizophrenia? http://t.co/OfZpWe98hh
Are you really at risk of attack by someone with schizophrenia? #mentalhealth #schizophrenia
[…] messages other patients do. And in the some areas of the media, there’s still an obsession over the relatively rare cases when a person with a mental health problem commits a serious violent […]
I’d like to suggest that the cause of the violence when it occurs is due to faulty use of the procedures that manage the risk assessment tools – “ways of working”.
CAMHS were so concerned for my safety at the end of 2015 that they commissioned a forensic risk assessment. That said that if my son had another psychosis it was “most likely” he would become violent and he needed to be closely monitored by CAMHS. By then there had been a.change of psychiatrist at CAMHS. She ignored (or never read?) the forensic report and discharged my son. One torturous year later, my son has been charged with attempted murder (of me) and the case is going through Crown Court. By now he was so unwell the MoJ issued a warrant for him to be moved from prison to a secure hospital where he is finally getting the help he needs. The police had to mop up the failings in CAMHS and social services who are over focused on ticking boxes and to a significant extent out of touch with reality in their ivory towers. Case now with the Ombudsman. In this specific example I would say the risk assessment was totally accurate but it’s a pity tax payers money was wasted for it to be ignored by people who really didn’t know what they were doing beyond their university degrees. The procedures, resources and experience is not sufficient.
This March/April I ended up in the Behavioral Health Unit of a hospital after I experienced violent convulsions from a new Prozac prescription. The first morning that I was there a schizophrenic patient asked if he could get into bed with me. I told him no and he said that he had asked me nicely. Luckily, they called me to the nurses station to get my meds (saved by the bell). There was another male patient with bipolar disorder/schizophrenia. He followed me around and had no concept of my personal space. He would grope and fondle me, said he wanted to f*** and devour me, and even walked in the shower room during my designated time. Thankfully, I hadn’t undressed yet.
I am in danger of my sister n law who is hearing voices to commit filicide and is abusing alcohol and possibly drugs. She is still working a full time job somehow in the medical field (!!!) but is a ticking time bomb. She has some kind of animosity towards me and keeps showing up uninvited and then gets very upset and out of control. We have had the police involved and social services but nothing could be done as there wasn’t enough “evidence”. I fear for my life and that of my family. The system has failed all of us.
I can’t imagine a Schizophrenic with parniod delusions ever seeking help. I know this is true for my brother in-law. He won’t go to a doctor or a dentist because he thinks they will put tracking devices in him..When is suggested that we go to a psychiatrist together to discuss the problems he became very upset and thretened to kill me and my whole family. TEN MINUTES LATER HE WAS ASKING ME TO TAKE HIM TO CHECK HIS MAIL.