Are People With Mental Illness Violent?

"The vast majority of the American public believes that persons suffering from depression, schizophrenia, alcohol dependence, and drug dependence pose a threat for violence toward self and others. (NMHA, 1999)"

According to Mental Health: A Report of the Surgeon General (1999), the discrimination and stigma associated with mental illnesses largely stem from the link between mental illness and violence in the minds of the general public. “For instance, 61 percent of Americans think that people with schizophrenia are likely to be dangerous to others,” notes the report of the President’s New Freedom Commission on Mental Health, Achieving the Promise: Transforming Mental Health Care in America (2003).

Many believe that education is the key to reducing the stigma associated with mental illness. Education does not reduce stigma. According to the paper Americans’ Views of Mental Health and Illness at Century’s End: Continuity and Change, "Between 1950 and 1996, the proportion of Americans who describe mental illness in terms consistent with violent or dangerous behavior nearly doubled." 

Why is this hurtful to society?

• As a result of the fear of violence, preference for social distance in most social settings between the public and those with mental health problems remains distressingly high. 
• Americans are hesitant to interact with people who have mental illnesses (Pescosolido, et.al., 1996): 
• 38 percent are unwilling to be friends with someone having mental health difficulties
• 64 percent do not want someone who has schizophrenia as a close coworker
• 68 percent are unwilling to have someone with depression marry into their family
• "The public is least willing to accept persons suffering from psychological problems as family members or coworkers."

“Most people who suffer from a mental disorder are not violent — there is no need to fear them. Embrace them for who they are — normal human beings experiencing a difficult time, who need your open mind, caring attitude, and helpful support.” (Grohol, 1998)

In fact, people with psychiatric disabilities are far more likely to be victims than perpetrators of violent crime. (Appleby, et.al., 2001)

On functionality:

• "Majority of Americans believe that persons suffering from a mental health problem (sans depression) are unable to manage finances or make treatment decisions."
• "When asked to characterize the severity of the problem encountered by persons experiencing depression, schizophrenia, alcohol dependence, and drug dependence, the vast majority of the public views these conditions as representing “very serious” problems."

Most people with mental illness are high-functioning. 12-month incidence of mental illness in U.S. is 26.2% of adult population. Severe mental illness (resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities) is concentrated in only 1/5 of these cases (5.8% of adult population).
Women constituting twice as many severe cases as men. However, paradoxically, women with mental disorders are seen as significantly less likely to pose a threat for dangerous or violent behavior

Lifetime and 12-month incidence of mental illness in the U.S. adult population.1

The cases of mental illness in which violence does exist, the violence is not the result of inherent deviancy or a diabolical nature of those with mental illness, but because of severe distress. We, the public, are to blame for this, because we do not provide anywhere near the sufficient treatment to treat mental health problems.

Violence and Mental Illness — How Strong is the Link? 

Much can be done to diminish the risk of violence among the mentally ill. A study that compared the prevalence of violence in a group of psychiatric patients during the year after hospital discharge with the rate in the community in which the patients lived showed no difference in the risk of violence between treated patients and people without a psychiatric disorder.5 Thus, symptoms of psychiatric illness, rather than the diagnosis itself, appear to confer the risk of violent behavior. So patients with schizophrenia who are free of the acute psychotic symptoms that increase this risk, such as having paranoid thoughts or hearing voices that command them to hurt others (called command auditory hallucinations), may be no more likely to be violent than people without a mental disorder. The study did not specifically monitor the treatments, but it seems possible that treating psychiatric illness does not just make patients feel better; it may also drastically reduce the risk of violent behavior.

Of course, because serious mental illness is quite rare, it actually contributes very little to the overall rate of violence in the general population; the attributable risk has been estimated to be 3 to 5% — much lower than that associated with substance abuse, for example. One study involving 802 adults with a psychotic or major mood disorder showed that violence was independently correlated with several risk factors, including substance abuse, a history of having been a victim of violence, homelessness, and poor medical health.4 The 1-year rate of violent behavior for subjects with none or only one of these risk factors was 2% — a prevalence close to the ECA study's estimate for the general population. Thus, violence in people with serious mental illness probably results from multiple risk factors in several domains.

"Large numbers of the American public assign primary responsibility for the costs of mental health treatment to the affected individual and private insurance companies. If necessary, these individuals assign secondary responsibility to the families of those with mental health problems."

• "Between 1957 and 1996 the percentage of the American public who indicated that they would seek informal support to deal with an anticipated nervous breakdown increased over 400 percent."
• "Americans see the utility of a wide variety of potential sources of help for those suffering from mental health problems, but when asked to indicate whom they would turn to first, the majority indicated they would seek help from family and friends."

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Violence and mental illness: an overview

It is important to keep in mind that both serious violence and serious mental disorder are rare events. Therefore, it is difficult to judge the practical importance of findings that may show an elevated risk of violence among samples of mentally ill as they tell us little about public risk.

One way of approaching this issue is ask who are the most likely targets of violence by the mentally ill: members of the general public or members of their close personal networks? Most recent studies suggest that violent incidents among persons with serious mental disorders are sparked by the conditions of their social life, and by the nature and quality of their closest social interactions (29). In the MacArthur Violence Risk Assessment Study (1), for example, the most likely targets of violence were family members or friends (87%), and the violence typically occurred in the home. Discharged patients were less likely to target complete strangers (10.7%) compared to their community controls (22.2%). Similarly, in a social network study that followed 169 people with serious mental disorder over thirty months (30), violence most frequently erupted in the family when relationships were characterized by mutual threat, hostility, and financial dependence; when there was a diagnosis of schizophrenia with concurrent substance abuse; and when outpatient mental health services were used infrequently. Of the over 3,000 social network members studied, only 1.5% were ever targets of violent acts or threats.

A related question asks to what extent do mentally ill contribute to the overall prevalence of community violence. Using data from the Epidemiologic Catchment Area studies conducted in the United States, Swanson (31) reported population attributable risks for self-reported physical violence. Attributable risk refers to the overall effect a factor has on the level of violence in the population. For those with a major mental disorder, the population attributable risk was 4.3%, indicating that violence in the community could be reduced by less than five percent if major mental disorders could be eliminated. The population attributable risk for those with a substance abuse disorder was 34%, and for those with a comorbid mental illness and substance abuse disorder it was 5%. Therefore, by these estimates, violence in the community might be reduced by only 10% if both major mental disorders and comorbid disorders were eliminated. However, violence could be reduced by over a third if substance abuse disorders were eliminated.

Using a similar approach, a Canadian study asked what proportion of violent crimes involving a police arrest and detention could be attributed to people with a mental disorder. They surveyed 1,151 newly detained criminal offenders representing all individuals incarcerated in a geographically defined area. Three percent of the violent crimes accruing to this sample were attributable to people with major mental disorders, such as schizophrenia or depression. An additional seven percent were attributable to offenders with primary substance abuse disorders. Therefore, if major mental illness and substance disorder could be eliminated from this population, the proportion of violent crime would drop by about 10% (32).

Other facts:

• "Americans in 1996 were significantly more likely (than in 1957 and 1976) to rely on prescription medications and mental health professionals when faced with an anticipated psychological problem. They are also much less likely to turn to a physician for help with these problems."
• "Nearly half of all Americans feel that the government should be spending more on mental health services, even if this additional spending requires new taxes. Only 1 in 10 Americans would prefer to
• see the government spend less on these services."
• good
• "Over two-thirds of the American public believe that the government “definitely” or “probably” has the
• responsibility to provide mental health services to those with psychological problems."
• good
• "Overwhelmingly, the American public believes that if treated, mental health problems will improve."
• true
• "They also believe, however, that if left untreated, these problems will not improve on their own."
• untrue
• "Americans are nearly uniform in their belief that legal means should be used if needed to force the hospitalization of mentally ill persons who represent a threat to themselves or others."

In the end, it is each individual's responsibility to create a world worth living in, and that means treating people with mental illness with the same respect as anybody else and providing sufficient health care.

SOURCE:
¹Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 2005 Jun;62(6):617-27.