In the JournalsPerspective

Psychiatric patients significantly more likely to be perpetrators and victims of violence

Patients with psychiatric disorders are significantly more likely to be victimized by or perpetrators of violence than those without psychiatric disorders, according to findings of a nationwide cohort study published in JAMA Psychiatry.

“The evidence base regarding perpetration risks needs to be interpreted in the context of subjection to violence among individuals with psychiatric disorders,” Amir Sariaslan, PhD, of the University of Helsinki in Finland, and colleagues wrote. “Reviews of previous research, expert opinion and advocacy groups report that the rate of subjection to violence is considerably higher than the perpetration of violence, and it is commonly suggested that this rate is approximately 10-fold.”

The researchers estimated the associations of numerous psychiatric disorders with the risks for subjection to violence and perpetration of violence among 250,419 patients included in Swedish nationwide registers who were identified as having psychiatric disorders. They matched these individuals by age and sex to 2,504,190 individuals in the general population, as well as to patients’ full biological siblings without psychiatric disorders (n = 194,788). Further, they differentiated patients with common psychiatric disorders using a hierarchical approach, and they also included patients with substance use disorders and personality disorders.

The researchers defined perpetration of violence as a violent crime conviction and subjection to violence as an outpatient visit, inpatient episode or death associated with any diagnosis of an injury that was purposefully inflicted by others. They found that patients with psychiatric disorders were more likely to be subjected to violence (7.1 [95% CI, 6.9-72.] vs. 7.5 [95% CI, 7.4-7.6] per 1,000 person years) and to perpetrate violence (1 [95% CI, 0.9-1] vs. 0.7 [95% CI, 0.7-0.7] per 1,000 person years) than matched individuals. Fully adjusted models revealed that patients were three to four times more likely than their siblings without psychiatric disorders to be either subjected to violence (adjusted HR = 3.4; 95% CI, 3.2-3.6) or to perpetrate violence (aHR = 4.2; 95% CI, 3.9-4.4). Those diagnosed with any psychiatric disorder were more likely to experience higher rates of violent outcomes, except for schizophrenia, which was not associated with the risk of subjection to violence, they noted.

“Our findings underscore the need to address comorbid substance use and personality disorders to develop scalable approaches that assess and manage the risk for subjection to and perpetration of violence in people with psychiatric disorders,” the researchers wrote.

In a related editorial, Paul S. Appelbaum, MD, of the New York Psychiatric Institute, provided a forward-looking assessment of these findings and their implication.

“Although violence perpetrated by people with mental disorders accounts for only a small proportion of violent incidents, to the extent that the frequency of such events can be diminished, people with the potential to be targeted by violence and incipient perpetrators will benefit,” Appelbaum wrote. “Similarly, reducing the rate of being a target of violence of people with mental disorders will benefit them directly and is likely to make it easier for them to reintegrate into the community. Thus, our focus going forward should be on identifying factors in the causal pathways to violence and being targeted by violence (not merely identifying correlates), testing interventions to find effectives answers and mustering the will and the resources to implement them.” – by Joe Gramigna

Disclosures: Appelbaum and Sariaslan report no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

Patients with psychiatric disorders are significantly more likely to be victimized by or perpetrators of violence than those without psychiatric disorders, according to findings of a nationwide cohort study published in JAMA Psychiatry.

“The evidence base regarding perpetration risks needs to be interpreted in the context of subjection to violence among individuals with psychiatric disorders,” Amir Sariaslan, PhD, of the University of Helsinki in Finland, and colleagues wrote. “Reviews of previous research, expert opinion and advocacy groups report that the rate of subjection to violence is considerably higher than the perpetration of violence, and it is commonly suggested that this rate is approximately 10-fold.”

The researchers estimated the associations of numerous psychiatric disorders with the risks for subjection to violence and perpetration of violence among 250,419 patients included in Swedish nationwide registers who were identified as having psychiatric disorders. They matched these individuals by age and sex to 2,504,190 individuals in the general population, as well as to patients’ full biological siblings without psychiatric disorders (n = 194,788). Further, they differentiated patients with common psychiatric disorders using a hierarchical approach, and they also included patients with substance use disorders and personality disorders.

The researchers defined perpetration of violence as a violent crime conviction and subjection to violence as an outpatient visit, inpatient episode or death associated with any diagnosis of an injury that was purposefully inflicted by others. They found that patients with psychiatric disorders were more likely to be subjected to violence (7.1 [95% CI, 6.9-72.] vs. 7.5 [95% CI, 7.4-7.6] per 1,000 person years) and to perpetrate violence (1 [95% CI, 0.9-1] vs. 0.7 [95% CI, 0.7-0.7] per 1,000 person years) than matched individuals. Fully adjusted models revealed that patients were three to four times more likely than their siblings without psychiatric disorders to be either subjected to violence (adjusted HR = 3.4; 95% CI, 3.2-3.6) or to perpetrate violence (aHR = 4.2; 95% CI, 3.9-4.4). Those diagnosed with any psychiatric disorder were more likely to experience higher rates of violent outcomes, except for schizophrenia, which was not associated with the risk of subjection to violence, they noted.

“Our findings underscore the need to address comorbid substance use and personality disorders to develop scalable approaches that assess and manage the risk for subjection to and perpetration of violence in people with psychiatric disorders,” the researchers wrote.

In a related editorial, Paul S. Appelbaum, MD, of the New York Psychiatric Institute, provided a forward-looking assessment of these findings and their implication.

“Although violence perpetrated by people with mental disorders accounts for only a small proportion of violent incidents, to the extent that the frequency of such events can be diminished, people with the potential to be targeted by violence and incipient perpetrators will benefit,” Appelbaum wrote. “Similarly, reducing the rate of being a target of violence of people with mental disorders will benefit them directly and is likely to make it easier for them to reintegrate into the community. Thus, our focus going forward should be on identifying factors in the causal pathways to violence and being targeted by violence (not merely identifying correlates), testing interventions to find effectives answers and mustering the will and the resources to implement them.” – by Joe Gramigna

Disclosures: Appelbaum and Sariaslan report no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

    Perspective
    Jack Rozel

    Jack Rozel

    Understanding and managing violence risk in patients with psychiatric illness is a critical issue for mental health professionals.  As most professionals are well aware, the risk of violent victimization of people with psychiatric illness is also an issue. A new study by Sariaslan and colleagues provides added clarity on the relative risks in a population cohort study from Sweden.

    This study compared the risk of violent behavior and victimization in 250,000 people with diagnosed psychiatric illness with 195,000 siblings and 2,504,000 other matched controls from the population in a large Swedish birth cohort across a time span of 40 years.  This extremely large-scale population and timeframe is exceptional in the canon of research on violence. Notably, and unlike prior research, this team found that people with psychiatric illness were only three to four times more likely than their siblings to be a perpetrator or victim, and that much of the difference in the rates of violence in patients with psychiatric disorder may have been driven by family and neighborhood factors.

    The study is substantially limited by the threshold required to qualify as engaging in violence (conviction for violent crime) or violent victimization (documented medical care with an ICD code for criminal victimization). As such, the study undercounts and misses violent behavior that does not lead to conviction or violent victimization that does not lead to medical care. As most clinicians appreciate, most of the violent behavior by the patients we care for does not end in conviction, and the barriers people with mental illness face after criminal victimization are profound.

    Perhaps the most significant take-home point for clinicians is the importance of family and community factors in driving risk of violence and victimization and that risk is not purely a product of diagnosis. This study adds significantly to our understanding of violent victimization and perpetration of mental illness. Although the results are not fully congruent with prior research, the difference in research design should lead us to consider these findings to supplement the body of literature and not to replace it.

    • Jack Rozel, MD, MSL
    • Medical Director
      Resolve Crisis Services of UPMC Western Psychiatric Hospital
      Associate professor of psychiatry and adjunct professor of law
      University of Pittsburgh
      Healio Psychiatry Peer Perspective Board member

    Disclosures: Rozel reports no relevant financial disclosures.