Violence and people with mental illness
First Paper: Edited by Dr. E. Fuller Torrey
SUMMARY: It is well known that the two major demographic predictors of violent behavior are male sex and younger age. It is also known that the two major clinical predictors of violent behavior are past history of violence and substance abuse (alcohol and/or drug). Recent studies have established that being severely mentally ill and not taking medication is a third major clinical predictor of violent behavior.
Severely mentally ill individuals who ARE taking their medication are NOT more dangerous than the general population.
- All studies of mental illness and violence done to date suggest that individuals with severe psychiatric disorders who are taking their medication are not more dangerous than the general population. Among all individuals, being a male and being a substance abuser (alcohol and/or drugs) are the largest predictors of who will become violent.
Severely mentally ill individuals who are NOT taking their medication ARE more dangerous than the general population.
Several early studies in the 1970s suggested this fact but were not well controlled. For example, a six-year follow-up of 301 patients discharged between 1972 and 1975 from a California state hospital reported that their arrest rate for “violent crimes” was 10 times the rate for the general population.
Sosowsky L. Explaining the increased arrest rate among mental patients: A cautionary note. American Journal of Psychiatry 1980;137:1602–1605.
A New York State study compared homicides committed by mentally ill persons in the years prior to widespread deinstitutionalization (1963–1969) with the years during widespread desinstitutionalization (1970–1975). There was a significant increase in homicides in the latter period. The authors conclude that “closer follow-ups of psychotic patients, especially schizophrenics, could do a lot to improve the welfare of the patient and community.”
Grunberg F, Klinger BI, Grumet BR. Homicide and community-based psychiatry. Journal of Nervous and Mental Disease 1978;166:868–874.
In reviewing these earlier studies on discharged psychiatric patients, Dr. Judith Rabkin concluded: “Arrest and conviction rates for the subcategory of violent crimes were found to exceed general population rates in every study in which they were measured.”
Rabkin J. Criminal behavior of discharged mental patients: a critical appraisal of the research. Psychological Bulletin 1979;86:1–-27.
The Epidemiological Catchment Area (ECA) surveys carried out 1980–1983 reported much higher rates of violent behavior among individuals with severe mental illness living in the community compared to other community residents. For example, individuals with schizophrenia were 21 times more likely to have used a weapon in a fight.
Swanson JW, Hozer CD, Ganju VK et. al. Violence and psychiatric disorder in the community: evidence from the Epidemiologic Catchment Area surveys. Hospital and Community Psychiatry 1990;41:761–770.
In an analysis of data from the ECA study, the authors noted that “mentally ill individuals with no treatment contact in the past six months had significantly higher odds of violence in the long term” and that “moderate levels of agitation and psychoticism increase the risk of violence.” They then conclude: “This would seem to provide a strong argument for providing more interventions targeted specifically to persons with combined mental illness and addictive disorders who are likely not to comply voluntarily with conventional outpatient therapies.”
Swanson J, Estroff S, Swartz M et. al. Violence and severe mental disorder in clinical and community populations: the effects of psychotic symptoms, comorbidity, and lack of treatment. Psychiatry 1997;60:1–22.
A study of inpatients diagnosed with schizophrenia reported an inverse correlation between their propensity to violence and their blood level of antipsychotic medication. Yesavage JA. Inpatient violence and the schizophrenic patient: an inverse correlation between danger-related events and neuroleptic levels. Biological Psychiatry 1982;17:1331–-1337.
A study of severely mentally ill patients in a state forensic hospital found a highly significant correlation (p 0.001) between failure to take medication and a history of violent acts in the community. Smith LD. Medication refusal and the rehospitalized mentally ill inmate. Hospital and Community Psychiatry 1989 40:491–496.
A study in a forensic hospital in England reported an association between violent behavior and untreated psychotic symptoms. According to the authors, “over 80 percent of the offenses of the psychotic [men] were probably attributable to their illness. . . . Within the psychotic group those driven to offend by their delusions were most likely to have been seriously violent, and psychotic symptoms probably accounted directly for most of the very violent behavior.” Taylor P. Motives for offending amongst violent and psychotic men. British Journal of Psychiatry 1985;147:491–498.
A 1990 study investigated violent behavior among severely mentally ill individuals in 1,401 randomly selected families who were members of the National Alliance for the Mentally Ill (NAMI). In the preceding year, 11 percent of these individuals were reported to have physically harmed another person. Steinwachs DM, Kasper JD, Skinner EA. Family Perspectives on Meeting the Needs for Care of Severely Mentally Ill Relatives: A National Survey (Arlington, Va.: National Alliance for the Mentally Ill, 1992).
A 9- to 12-year follow-up of 192 men with schizophrenia who had been detained by the Secret Service when they had presented themselves at the White House with delusional demands found that they had a subsequent arrest rate for violent crimes 1.6 times (with no past history of violence) to 4.8 times (with a past history of violence) that of the general population. Shore D, Filson CR, Rae DS. Violent crime arrest rates of White House case subjects and matched control subjects. American Journal of Psychiatry 1990;147:746–750.
A study of 133 outpatients with schizophrenia showed that “13 percent of the study group were characteristically violent.” Having inadequately treated symptoms of delusions and hallucinations was one of the predictions of violent behavior. Specifically, “71 percent of the violent patients . . . had problems with medication compliance, compared with only 17 percent of those without hostile behaviors,” a difference that was statistically highly significant (p 0.001). Bartels J, Drake RE, Wallach MA et. al. Characteristic hostility in schizophrenic outpatients. Schizophrenia Bulletin 1991;17:163–171.
A Swedish study of 644 individuals with schizophrenia followed for 15 years reported that they committed violent offenses at a rate four times greater than the general population.Lindqvist P, Allebeck P. Schizophrenia and crime: a longitudinal follow-up of 644 schizophrenics in Stockholm. British Journal of Psychiatry 1990;157:345–350.
Another Swedish study, using case registers, examined the criminal records of all individuals born in Stockholm in 1953 and still living there 30 years later. Men and women with a severe mental illness were 4.2 times (men) and 27.5 times (women) more likely to have been convicted of a violent crime compared to individuals with no psychiatric diagnosis. Hodgins, S. Mental disorder, intellectual deficiency, and crime. Archives of General Psychiatry 1992;49:476–483.
In a follow-up of patients released from a psychiatric hospital, Dr. Henry Steadman et al reported that “27 percent of released male and female patients report at least one violent act within a means of four months after discharge.” Monahan J. Mental disorder and violent behavior. American Psychologist 1992;47:511–-521.
Among 20 individuals who pushed or tried to push another person in front of the subway in New York, all except one was severely mentally ill and offered motives directly related to their untreated psychotic symptoms. Martell DA, Dietz PE. Mentally disordered offenders who push or attempt to push victims onto subway tracks in New York City. Archives of General Psychiatry 1992;49:472–475.
In a carefully controlled study comparing individuals with severe mental illness living in the community in New York with other community residents, the former group was found to be three times more likely to commit violent acts such as weapons use or “hurting someone badly.” The sicker the individual, the more likely they were to have been violent.Link BG, Andrews H, Cullen FT. The violent and illegal behavior of mental patients reconsidered. American Sociological Review 1992;57:275–292.
A study of 538 individuals with schizophrenia living in London reported that the men had a 3.9 times and women a 5.3 times greater risk for conviction for assault and serious violence compared to a control group with other psychiatric diagnoses.Wesseley SC, Castle D, Douglas AJ et. al. The criminal careers of incident cases of schizophrenia. Psychological Medicine 1994;24:483-502.
A study of 348 inpatients in a Virginia state psychiatric hospital found that patients who refused to take medication “were more likely to be assaultive, were more likely to require seclusion and restraint, and had longer hospitalizations.”
Kasper JA, Hoge SK, Feucht-Haviar T et. al. Prospective study of patients’ refusal of antipsychotic medication under a physician discretion review procedure. American Journal of Psychiatry 1997;154:483–489.
A study in Switzerland compared 282 men with schizophrenia with a matched control group in the general population. The patients were five times more likely to have been convicted of violent crimes, mostly “assaults resulting in bodily harm.” The more acutely ill the patient was, the more likely he was to have been violent.
Modestin J, Ammann R. Mental disorder and criminality: male schizophrenia. Schizophrenia Bulletin 1996;22: 69–82.
A study of homicides in Finland reported that “the risk of committing a homicide was about 10 times greater for schizophrenia patients of both genders than it was for the general population.” For men “schizophrenia without alcoholism increased the odds ratio more than 7 times; schizophrenia with coexisting alcoholism more than 17 times.”
Eronen M, Tiihonen J, Hakola P. Schizophrenia and homicidal behavior. Schizophrenia Bulletin 1996;22:83–89.
In another study in Finland, an unselected birth cohort of 11,017 individuals was followed for 26 years. Men with schizophrenia without alcoholism were 3.6 times more likely to commit a violent crime than men without a psychiatric diagnosis. Men with both schizophrenia and alcoholism were 25.2 times more likely to commit a violent crime.
Rasanen P, Tiihonen J, Isohanni M et.al. Schizophrenia, alcohol abuse, and violent behavior: a 26-year follow-up study of an unselected birth cohort. 1998;Schizophrenia Bulletin 24:437–441.
In the three-site MacArthur Foundation Study of violence and mental illness, 17.4 percent of the patients were violent in the 10-week period prior to hospitalization, during which time they were not being treated, compared to an average of 8.9 percent for the five 10-week periods after hospitalization during which most of them were being treated.
Steadman HJ, Mulvey EP, Monahan J et. al. Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighborhoods. Archives of General Psychiatry 1998;55:393–401.
An English study of 1,015 forensic patients with severe mental illness (“functional psychosis”) reported that the diagnosis of “schizophrenia was most strongly associated with personal violence” and that “more than 75 percent of those with a psychosis were recorded as being driven to offend by their delusions.” The authors concluded that “treatment appears as important for public safety as for personal health.”
Taylor PJ, Leese M, Williams D et. al. Mental disorder and violence. British Journal of Psychiatry 172:218–226, 1998.
A 10-year follow-up of 1,056 severely mentally ill patients discharged from mental hospitals in Sweden in 1986 reported that “of those who were 40 years old or younger at the time of discharge, nearly 40 percent had a criminal record as compared to less than 10 percent of the general public.” Furthermore, “the most frequently occurring crimes are violent crimes.”
Belfrage H. A ten-year follow-up of criminality in Stockholm mental patients. British Journal of Criminology 1998;38:145–155.
A study of 331 individuals with severe mental illness reported that 17.8 percent “had engaged in serious violent acts that involved weapons or caused injury.” It also found that “substance abuse problems, medication noncompliance, and low insight into illness operate together to increase violence risk.”
Swartz MS, Swanson JW, Hiday VA et. al. Violence and severe mental illness: the effects of substance abuse and nonadherence to medication. American Journal of Psychiatry 1998;155:226–231.
A study of 63 inpatients with schizophrenia in Spain reported that the best predictors of violent behavior were being sicker (i.e., higher scores on symptom measures) and less insight into their illness. “The single variable that best predicted violence was insight into psychotic symptoms.”
Arango C, Barba AC, Gonzalez-Salvador T et. al. Violence in schizophrenic inpatients: a prospective study. Schizophrenia Bulletin 1999;25:493–503.
A study of 961 young adults in New Zealand reported that individuals with schizophrenia and associated disorders were two-and-one-half times more likely than controls to have been violent in the past year. If the person was also a substance abuser, the incidence of violent behavior was even higher.
Arseneault L, Moffitt TE, Caspi A et. al. Mental disorders and violence in a total birth cohort. Archives of General Psychiatry 2000;57:979–986.
A four-state (New Hampshire, Connecticut, Maryland, and North Carolina) study of 802 adults with severe mental illness (64 percent schizophrenia or schizoaffective disorder, 17 percent bipolar disorder) reported that 13.6 percent had been violent within the previous year. “Violent” was defined as “any physical fighting or assaultive actions causing bodily injury to another person, any use of lethal weapon to harm or threaten someone, or any sexual assault during that period.” Those who had been violent were more likely to have been homeless, to be substance abusers, and to be living in a violent environment. Those who had been violent were also 1.7 times more likely to have been noncompliant with medications. As has been found in other such studies, the women with severe psychiatric disorders were almost as likely to have been violent (11 percent) as were the men (15 percent). Because the data on violent behavior were collected by self-report, the authors suggested “that our findings are probably conservative estimates of the true prevalence of violent behavior for persons with SMI.” They concluded “that risk of violence among persons with SMI is a significant problem” and “is substantially higher than estimates of the violence rate for the general population.”
Swanson JW, Swartz MS, Essock SMet al. The social-environmental context of violent behavior in persons treated for severe mental illness. American Journal of Public Health 2002;92:1523–1531.
A study in Ohio compared 122 patients with schizophrenia who had committed violent acts with 111 patients with schizophrenia who had not committed such acts. The violent patients had significantly more prominent symptoms and significantly less awareness of their illness.
Friedman L, Hrouda D, Noffsinger S et. al. Psychometric relationships of insight in patients with schizophrenia who commit violent acts. Schizophrenia Research 2003;60:81.
A study of 1,011 outpatients with severe psychiatric disorders in five states reported that “community violence was inversely related to treatment adherence,” i.e., the less medication individuals took, the more likely they were to become violent.”
Elbogen EB, Van Dorn RA, Swanson JW et al. Treatment engagement and violence risk in mental disorders. British Journal of Psychiatry 2006;189:354–360.
In Singapore, 110 individuals were charged with murder between 1997 and 2001. Among these, 7 had schizophrenia, 1 had bipolar disorder, and 2 had delusional disorders. Thus, 10 out of 110 (9 percent) had psychotic disorders.
Koh KGWW, Gwee KP, Chan YH. Psychiatric aspects of homicide in Singapore: a five-year review (1997–
A study in New York assessed 60 severely mentally ill men who had been charged with violent crimes. The author reported that medication noncompliance and lack of awareness of illness both played significant roles in causing the men’s violent behavior.
Alia-Klein N, O’Rourke TM, Goldstein RZ et al. Insight into illness and adherence to psychotropic medications are separately associated with violence severity in a forensic sample. Aggressive Behavior 2007;33:86–96.
A study of 907 individuals with severe mental illness reported that those who were violent were “more likely to deny needing psychiatric treatment.” The authors concluded that “clinical interventions that address a patient’s perceived need for psychiatric treatment, such as compliance therapy and motivational interviewing, appear to hold promise as risk management strategies”.
Elbogen EB, Mustillo S, Van Dorn R et al. The impact of perceived need for treatment on risk of arrest and violence among people with severe mental illness. Criminal Justice and Behavior 2007;34:197–210.
A review of 10 studies of homicides committed by individuals with psychoses reported that such homicides are much more likely to occur during the person’s initial episode of psychosis, before he/she has been treated. According to the authors: “The rate ratio of homicide in the first episode of psychosis in these studies was 15.5 times the annual rate of homicide after treatment for psychosis.”
Nielssen O, Large M. Rates of homicide during the first episode of psychosis and after treatment: a systematic review and meta-analysis. Schizophrenia Bulletin Advance Access, published November 5, 2008.
In reviewing many of these studies in 1992, Prof. John Monahan concluded: “The data that have recently become available, fairly read, suggest the one conclusion I did not want to reach: Whether the measure is the prevalence of violence among the disordered or the prevalence of disorder among the violent, whether the sample is people who are selected for treatment as inmates or patients in institutions or people randomly chosen from the open community, and no matter how many social and demographic factors are statistically taken into account, there appears to be a relationship between mental disorder and violent behavior.”
Monahan J. Mental disorder and violent behavior. American Psychologist 1992;47:511–521.
In a 1996 editorial reviewing such studies, Dr. Peter Marzuk added: “In the last decade, however, the evidence showing a link between violence, crime, and mental illness has mounted. It cannot be dismissed; it should not be ignored.”
Marzuk PM. Violence, crime, and mental illness. Archives of General Psychiatry 1996;53:481–486.
A 2001 review article on violence and schizophrenia, authored by researchers at the Institute of Psychiatry in London, concluded: “It is now generally accepted that people with schizophrenia, albeit by virtue of the activity of a small subgroup, are significantly more likely to be violent than members of the general population, but the proportion of societal violence attributable to this group is small.” The authors also noted that “comorbid substance abuse considerably increases the risk.” They emphasized that the proportion of total violence in society attributable to schizophrenia is small, specifically “below 10 percent.”
Walsh E, Buchanan A, Fahy T. Violence and schizophrenia: examining the evidence. British Journal of Psychiatry 2001;180: 490–495.
In countries such as the United States, where violence is relatively common, the percentage of violent acts attributable to individuals with severe psychiatric disorders is comparatively low, probably no more than 5 percent. In many other countries where violence is less common, the percentage of violent acts attributable to individuals with severe psychiatric disorders may be proportionately greater. Thus, in New Zealand, a study reported that “just over 10 percent of past-year violence committed by these young adults was attributable to schizophrenic spectrum disorders.”
Walsh E, Buchanan A, Fahy T. Violence and schizophrenia: examining the evidence. British Journal of Psychiatry 2001;180: 490–495.
Individuals with severe mental illnesses are probably responsible for approximately 10 percent of homicides in the United States.
- A 1988 Department of Justice study reported that individuals with a history of mental illness (not including drug or alcohol abuse) were responsible for 4.3 percent of the homicides in the United States, or 897 out of 20,860. In instances in which the homicide occurred among family members, the percentage was much higher, e.g., in 25 percent of cases in which an individual killed his/her parent, that individual was mentally ill. If the 4.3 percentage held in 1993, the total mental illness-related homicides would have been 1,055 (4.3 percent of 24,530). It seems reasonable to assume that most of these would have been preventable if the individual had been receiving psychiatric treatment.
Dawson JM, Langan PA. Murder in families (Washington, D.C.: Bureau of Justice Statistics, U.S. Department of Justice, 1994).
Between 1970 and 1975 in Albany County, New York, a study was done on all 28 homicides committed there. Eight homicides (29 percent) were committed by individuals with schizophrenia. Most of them were not being treated at the time of the crime, leading the authors to conclude that “closer follow-ups of psychotic patients, especially schizophrenics, could do a lot to improve the welfare of the patient and community.”
Grunberg F, Klinger BI, Grumet B. Homicide and deinstitutionalization of the mentally ill. American Journal of Psychiatry 1977;134:685–687. Grunberg F, Klinger BI, Grumet BR. Homicide and community-based psychiatry. Journal of Nervous and Mental Disease. 1978;166:868–874.
A 1985 study reported that 10 percent (7 out of 71) of all homicides 1978–1980 in Contra Costa County in California were carried out by individuals diagnosed with schizophrenia. All had been evaluated psychiatrically prior to the crime and had refused medication.
Wilcox DE. The relationship of mental illness to homicide. American Journal of Forensic Psychiatry 1985;6:3–15.
In Indiana, researchers examined the records of 518 individuals in prison who had been convicted of homicide between 1990 and 2002. Among the 518, 53 (or 10.2 percent) had been diagnosed with schizophrenia (n=27), bipolar disorder (n=12), or other psychotic disorders not associated with drug abuse (n=14). An additional 42 individuals had been diagnosed with mania or major depressive disorder. It should be emphasized that the study included only those who had been sentenced to prison and did not include those individuals who had committed homicides and were subsequently found to be incompetent to stand trial or not guilty by reason of insanity and therefore sent to a psychiatric facility instead of prison. Thus, the 10.2 percent is an undercount. The authors also noted that 80 percent of the mentally ill individuals who committed homicides had received past psychiatric treatment but that “many of the offenders were not receiving treatment” at the time of the homicide.
Matejkowski JC, Cullen SW, Solomon PL. Characteristics of persons with severe mental illness who have been incarcerated for murder. Journal of the American Academy of Psychiatry and the Law 2008;36:74–86.
In 2007, there were 16,929 homicides in the United States. If individuals with severe psychiatric disorders were responsible for only 10 percent of these, that would be approximately 1,690 homicides.
U.S. crime rates (http://www.disastercenter.com/crime/uscrime.htm).
At least 10 percent of males with severe mental illnesses become violent, and a lesser percentage of females do. In the United States, this would total approximately 200,000–250,000 individuals.
There are very few data that can be used to estimate the percentage of severely mentally ill individuals who become violent. The best study used the Danish psychiatric case register, covering the whole country, and convictions for criminal offenses. Between1978 and 1990, 6.7 percent of males and 0.9 percent of females with “major mental disorders” (psychoses) were convicted of a violent crime (“all offenses involving interpersonal aggression or a threat thereof”) compared with 1.5 percent males and 0.1 percent females among individuals with no psychiatric diagnosis. Since these are only convictions, it can be assumed that another unknown percentage committed a violent act for which they were not charged or convicted.
Hodgins S, Mednick SA, Brennan PA, et.al. Mental disorder and crime. Archives of General Psychiatry 1996;53:489–496.
The incidence of violent behavior among severely mentally ill individuals in the studies discussed under II above includes:
11 percent in the survey of NAMI families
13 percent among outpatients with schizophrenia
8.9 percent in treatment and 17.4 percent not in treatment in the MacArthur Foundation Study
17.8 percent among inpatients with severe mental illness
In light of the above, it seems reasonable to estimate that at least 10 percent of males with a severe mental illness exhibit violent behavior at some time during their illness and a lesser percentage of females do so. Since there are at least 4 million individuals in the United States with schizophrenia and manic-depressive disorder, then approximately 200,000–250,000 severely mentally ill individuals are or have been violent.
Publicized episodes of violence by individuals with severe mental illnesses are a major cause of discrimination and stigma against this group.
Following highly publicized attacks on prominent German officials by individuals with severe mental illnesses, there was a measurable “marked increase in desired social distance from mentally ill people immediately following [the] violent attacks.” The increased social distance and consequent stigma slowly decreased over time but had not returned to baseline two years later.
Angermeyer MC, Matschinger H. The effect of violent attacks by schizophrenic persons on the attitude of the public towards the mentally ill. Social Science and Medicine 1996;43:12:1721–1728.
A study using university volunteers demonstrated that reading a newspaper article reporting a violent crime committed by a mental patient led to increased “negative attitudes toward people with mental illnesses.”
Thorton JA, Wahl OF. Impact of a newspaper article on attitudes toward mental illness. Journal of Community Psychology 1996;24:17–25.
Such studies suggest that it is futile to try to decrease stigma against individuals with mental illness until the problem of violence is addressed. This was noted as early as 1981 by Dr. Henry Steadman who observed: “Recent research data on contemporary populations of ex-mental patients supports these public fears [of dangerousness] to an extent rarely acknowledged by mental health professionals. . . . It is [therefore] futile and inappropriate to badger the news and entertainment media with appeals to help destigmatize the mentally ill.”
Steadman, HJ. Critically reassessing the accuracy of public perceptions of the dangerousness of the mentally ill. Journal of Health and Social Behavior 1981;22:310–316,1981.
In 1992 Dr. John Monahan added:
“The data suggest that public education programs by advocates for the mentally disordered along the lines of ‘people with mental illness are no more violent than the rest of us’ may be doomed to failure. . . . And they should: the claim, it turns out, may well be untrue.”
Monahan J. Mental disorder and violent behavior. American Psychologist 1992;47:511–521.
The 1999 Surgeon General’s Report on Mental Health noted that “the perception of people with psychosis as being dangerous is stronger today than in the past. . . . People with mental illness, especially those with psychosis, are perceived to be more violent than in the past” (Surgeon General’s Report, p. 7).
U. S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General. (Rockville, Md.: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999).See the briefing paper “Stigma and Violence” for a more complete discussion of this issue.
Violence and schizophrenia
The violence issue among individuals with schizophrenia is a treatment issue, nothing more nor less.
By Dr. E. Fuller Torrey
Schizophrenia Research 88 (2006) 3–4
The recent killing of Wayne Fenton by a patient with untreated schizophrenia reminds us of a fact that we too often ignore. A subset of people with schizophrenia and other psychoses are dangerous if their paranoid delusions and other symptoms are not treated, especially if they are also abusing alcohol or street drugs.
Eight major studies of violence among seriously mentally ill individuals have been reported in the United States since 1990. Together they show that 5 to 10% of such individuals commit acts of serious violence each year. The studies also show the importance of treatment in reducing this violence. For example in the CATIE study the incidence of violence was very low because all participants were receiving antipsychotic medications.
Similarly in the MacArthur Violence Risk Assessment study the incidence of violence among treated patients was much lower than among those not taking medications. Homicides are the best documented and supreme expression of violence. In the United States only one small study of homicides committed by mentally ill individuals has been carried out; in Contra Costa County in California from 1978 to 1980 there were 7 individuals with schizophrenia and 1 other with a drug-induced psychosis among 71 total homicides. In European and Commonwealth nations in recent years, 13 such studies have been done. Individuals with schizophrenia and other psychoses were found to be responsible for an average of 9.4% (range: 5.3 to 17.9) of all homicides. The United States has a higher total homicide rate than most other countries so the percentage of homicides attributable to individuals with severe psychiatric disorders will be somewhat lower. Thus it seems apparent that individuals with psychoses are responsible for at least 5% of homicides in America. The massive discharge of patients from state psychiatric hospitals, followed by the failure to treat many of them, was well underway by 1966. During the intervening 40 years in the U.S. there have been 742,691 total homicides, of which a minimum of 37,134 (5%) were attributable to individuals with severe psychiatric disorders, almost all of whom were not being treated. As such, almost all of these were preventable homicides.
The most common victims of such homicides are family members, especially mothers. Mental health professionals are not uncommon but not rare victims. For example, in Oregon two psychiatrists were killed by patients in a single year.
The violence issue among individuals with schizophrenia is a treatment issue, nothing more nor less. In virtually every case it has been found that the individuals responsible for such homicides, like the young man who killed Dr. Fenton, were not taking medication. The problem is that approximately half of all individuals afflicted with schizophrenia have moderate or severe anosognosia; they are neurologically impaired and thus unable to perceive their own illness or need for medication. Laws governing the treatment of mentally ill individuals in the United States ignore this fact and make involuntary treatment exceedingly difficult to carry out. Several studies have shown a correlation between anosognosia and noncompliance with medication and with violent behavior.
The solution is assisted treatment for individuals with schizophrenia who have anosognosia and are thought to be dangerous. This can be accomplished by conservatorships, conditional release, or by outpatient commitment. Maryland, where Dr. Fenton was killed, is one of only eight states with no provision for outpatient commitment. In most states the laws are written in such a way that the family of the mentally ill person and mental health professionals can do nothing until the person demonstrates dangerousness. Dr. Fenton paid the ultimate price for Maryland’s inadequate laws.
Studies have shown that the use of conditional release and outpatient commitment reduce violence dramatically. In North Carolina outpatient commitment reduced the incidence of violence from 42 to 27% when the commitment was continued for at least 6 months. In New York, where the outpatient commitment statute is called Kendra’s law, a recent study reported that its use reduced the incidence of those who physically harmed others from 15 to 8%.
However it is considered politically incorrect to promote outpatient commitment or other forms of involuntary treatment. As a consequence organizations like the two APAs and NAMI are largely silent on this issue. Others, like the Mental Health Association and the Bazelon Center even deny the link between untreated schizophrenia and violence despite overwhelming evidence to the contrary. The only organization actively trying to change state treatment laws to take into account the reality of anosognosia is the Treatment Advocacy Center.
Wayne Fenton was a friend and colleague for whom I had great respect. He was dedicated to improving the treatment for individuals with schizophrenia. As professionals, the most important thing we can do to honor his memory is to speak out on the issue of violence and to promote treatment laws that reduce it. As noted by Swanson and Holzer: “No one is served by ignoring the evidence that mental illness is associated with some increased risk for assaultive behavior (Swanson and Holzer, 1991).”
Swanson, J.W., Holzer, C.E., 1991. Violence and ECA data. Letter. Hospital and Community Psychiatry 42, 954–955.