David Baxter PhD
Late Founder
Violence and schizophrenia
by E. Torrey Fuller
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).?
REFERENCES
Swanson, J.W., Holzer, C.E., 1991. Violence and ECA data. Letter. Hospital and Community Psychiatry 42, 954?955.
by E. Torrey Fuller
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).?
REFERENCES
Swanson, J.W., Holzer, C.E., 1991. Violence and ECA data. Letter. Hospital and Community Psychiatry 42, 954?955.
