Violent Acts and Being the Target of Violence Among People With Mental Illness—The Data and Their Limits

Abstract

Evidence has accumulated over the last 40 years indicating increased rates of violent perpetration and being the target of violence among people with mental illness. Landmark data collected in the early 1980s by the Epidemiologic Catchment Area study found a 12-month prevalence of 12% for any type of violence among people with mental disorders, which dropped to 7% if people with comorbid substance abuse (DSM-III) were excluded, compared with 2% in the general population. 1 Similar magnitudes of increased risk have been found in subsequent studies 2 and meta-analyses, 3 although the absolute rates of violence vary, probably because of differences in the populations sampled, outcome measures, and means of ascertainment. 4 However, despite the greater risk associated with mental disorders, the proportion of violence accounted for by mental disorder is small, with 1-year attributable risk estimated at 4% in the Epidemiologic Catchment Area analyses. 1 Being targeted by violence also has been shown consistently to be elevated among people with mental disorders, with most studies focusing on severe mental disorders. 5,6 Vulnerability may be enhanced by factors particularly associated with psychotic disorders, including homelessness and substance use, along with symptoms that may provoke violence by others, such as delusions and hallucinations. 6 Studies also confirm an association between being a perpetrator and being a target of violence, with a pooled sample from 5 studies showing that either status led to an 11-fold increase in the likelihood of the other. 7 However, findings on the degree of increased risk of being targeted by violence compared with people without mental disorders vary across studies.In this issue of JAMA Psychiatry, Sariaslan and colleagues 8 report being targeted by violence and violence perpetration data from a 20-year Swedish birth cohort of more than a quarter million people, comparing people with diagnoses of mental disorders with a comparison group without diagnoses from the general population and their own siblings without diagnoses. With a mean of 7.3 years of follow-up data after onset, overall rates of being targeted by violence and perpetration were low (approximately 7 per 1000 person-years), but the mentally disordered group was at elevated risk of being a target and perpetrator of violence. Without adjusting for confounders, the hazard ratios reflecting increased risk for being a target of violence and perpetration were approximately 7 and 11, respectively. However, in contrast to previous studies, the authors controlled not just for confounders that included sex, birth year, and parental characteristics, but also histories of violent involvement and unmeasured familial factors, the latter

A Retrospective Observational Study of Psychosocial Determinants and Psychiatric Diagnoses of Mass Shooters in the United States

“…Rather, it is intended to bring more awareness of the possibility of the under-diagnosis of mental disorders in perpetrators of violence so they can be accurately psychiatrically diagnosed. In fact, most individuals who suffer from schizophrenia and are appropriately treated with antipsychotic medication are not more violent and do not commit violent crimes more frequently than the rest of the population (Appelbaum, 2020;Buchanan et al, 2019). Typically, most violent behavior by those who suffer from schizophrenia occurs before treatment is initiated (Buchanan et al, 2019).…”

Domestic Mass Shooters

“…Having said that, the vast majority of the seriously mentally ill, who are appropriately diagnosed and treated with medication, are not more violent and do not commit violent crimes more frequently than the rest of the population 9,10 . Furthermore, poor medication adherence, usually associated with substance use, but not just baseline symptoms of psychosis, significantly predicts violence 9 .…”