Over two years ago, PsychOdyssey editorialized on this problem with copious academic references. It seems a good time to re-read it, so we offer it again to help leaven the public discourse on the highly overwrought association of violence and mental illness.
PsychOdyssey Op-Ed, June 4, 2013
John Monahan, a great New Jersey community mental health leader and retired CEO of Greater Trenton Behavioral Health (now part of Oaks Integrated Care)
John Monahan, CEO of Greater Trenton Behavioral Healthcare in Trenton, NJ, is a leader in New Jersey’s mental health field. He has written a fine editorial in his local Trenton Times, entitled “Mental Illness Should Not Be The Scapegoat For Violence”. For his editorial and his leadership we commend Mr. Monahan. He is right: the issue of violence is not about mental illness per se. Those with mental illness who commit violence are a small minority—and who usually have one tragic fact in common: lack of sufficient (or any) treatment.
To reduce violence, especially gun violence, society would be far better served by concentrating on urban gang warfare and continuing “stop and frisk” policies. To reduce the small percentage of violence by those with serious mental illness, we should get them not unconstitutionally listed in some national registry, but earlier and better assessed and into treatment at more good community mental health agencies like Greater Trenton Behavioral Health.
Above all, let’s also keep all the facts in view—and in perspective. From our own research, here are 10 important points that PsychOdyssey has learned about violence and mental illness:
1. Statistically speaking, yes, there is a moderate association between schizophrenia and violence (Matthias & Angermeyer, 2000; Mulvey, 1994).
2. But severe mental illness alone does not independently predict violent behavior. Those with mental illness exhibiting violence do so mostly because of other factors (Elbogen & Johnson, 2009).
3. One such factor is substance abuse. The association of substance abuse and violence is far greater (Matthias & Angermeyer, 2000) than of schizophrenia and violence.
4. So, those with schizophrenia who abuse substances are much more prone to violence than those who don’t (Elbogen & Johnson, 2009; Steadman Hj & et al., 1998).
5. In any event, when someone with schizophrenia is violent, it is mostly towards other family members and rarely towards strangers (Ferriter & Huband, 2003).
6. The different symptoms of schizophrenia (e.g,, “positive” like hallucinations and delusions; “negative” like alogia, anhedonia, and avolition) factor differently in any particular association with violence. There is no one consistent risk factor for violence among those with schizophrenia who exhibit violence (Swanson, Swartz, Van Dorn, & et al., 2006).
7. 4 million Americans have severe psychiatric disorders. 10% of these (400,000) would be problematic if not treated. 1% (only 40,000) are estimated to be “dangerous” if not treated (Torrey, 2008). By contrast, the FBI says there are 1.4 million active gang members (Federal Bureau of Investigation, 2013).
8. While those with schizophrenia may be relatively more prone to violence than those without it, the relative incidence of violence caused by those with schizophrenia than by those without is small (Walsh, Buchanan, & Fahy, 2002).
9. Why is treatment critical? Because the association of violence and schizophrenia is 15 times higher for those not being treated than for those being treated (Nielssen & Large, 2010).
10. In any event, current research about the association of violence and schizophrenia is limited and needs to increase and improve (Mulvey, 1994).
Elbogen, Eric B., & Johnson, Sally C. (2009). The intricate link between violence and mental disorder: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry, 66(2), 152-161. doi: 10.1001/archgenpsychiatry.2008.537
Federal Bureau of Investigation. (2013). 2011 national gang threat assessment: Emerging trends. from http://www.fbi.gov/stats-services/publications/2011-national-gang-threat-assessment
Ferriter, M., & Huband, N. (2003). Experiences of parents with a son or daughter suffering from schizophrenia. Journal of Psychiatric & Mental Health Nursing, 10(5), 552. doi: 10.1046/j.1365-2850.2003.00624.x
Matthias, & Angermeyer, C. (2000). Schizophrenia and violence. Acta Psychiatrica Scandinavica, 102, 63-67. doi: 10.1034/j.1600-0447.2000.00012.x
Mulvey, Edward P. (1994). Assessing the evidence of a link between mental illness and violence. Hospital & Community Psychiatry, 45(7), 663-668.
Nielssen, Olav, & Large, Matthew. (2010). Rates of homicide during the first episode of psychosis and after treatment: A systematic review and meta-analysis. Schizophrenia Bulletin, 36(4), 702-712. doi: 10.1093/schbul/sbn144
Steadman H.J., Mulvey, E. P., Monahan J. [no relation], & et al. (1998). Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighborhoods. Archives of General Psychiatry, 55(5), 393-401. doi: 10.1001/archpsyc.55.5.393
Swanson, J.W., Swartz, M. S. , Van Dorn, R. A., & et al. (2006). A national study of violent behavior in persons with schizophrenia. Archives of General Psychiatry, 63(5), 490-499. doi: 10.1001/archpsyc.63.5.490
Torrey, E. Fuller. (2008). The insanity offense. New York: W.W. Norton & Co., Inc.
Walsh, Elizabeth , Buchanan, Alec, & Fahy, Thomas. (2002). Violence and schizophrenia: examining the evidence. The British Journal of Psychiatry, 180(6), 490-495. doi: 10.1192/bjp.180.6.490