Mental Illness and Violence – Challenges and Solutions

Are people with serious mental illness more prone to violence than the general population?

In the aftermath of almost weekly mass shootings and other acts of extreme violence, this question inevitably emerges.

Beliefs, research and data

A 2013 Gallup poll found that 45 percent of Americans believe that mental illness is a key factor in the increase in gun violence. A 2006 General Social Survey reported by Harvard found that 60 percent of Americans thought that persons with schizophrenia were prone to violence based solely on their diagnosis.

Substantial research presents a markedly different point of view – people with mental illness are responsible for 5 percent or less of violent interactions. Given that 4.2 percent of the general population also carries a diagnosis of a serious mental illness (SMI), this would suggest relative proportionality – individuals with SMI conditions are no more or less likely to be the source of violence. Research also consistently finds that people with mental health conditions are 2.5 times more likely to be the victim of violence, compared to the general population.

However, the answer is still not simple. Other considerations enter the picture. How does substance use affect the ‘mental-condition-equals-likelihood-of-violence’ equation? What about the relationship with mental illness and suicide by firearms?

People with mental illness are responsible for 5 percent or less of violent interactions. Given that 4.2 percent of the general population also carries a diagnosis of a serious mental illness (SMI), this would suggest relative proportionality – individuals with SMI conditions are no more or less likely to be the source of violence.

When it comes to research, alternate studies often yield variable results.

A Psychiatry MMC article cites research indicating on the one hand that, “Mental illness may increase the likelihood of committing violence in some individuals, but only a small part of the violence in society can be ascribed to mental health patients.” The article goes on to state “Overall, those psychiatric patients who are violent have rates of repeated aggression somewhere between the general population and a criminal cohort.” In other words, for a select subset of individuals with SMI, their mental health condition seems to accelerate episodes of violent activity.

Additional research points to a correlation between other forms of mental illness and violence. A Social Psychiatry and Psychiatric Epidemiology article states that antisocial personality disorder (a mental health condition typically excluded from the SMI category) is a risk factor for violence. The article also states that “individuals diagnosed with major mental disorders have an overall higher risk than the general population for criminal (including violent) offending”, largely attributable to co-occurring substance use. Substance use disorders (SUD) combined with other mental health conditions increase the likelihood of violent behavior.

The Treatment Advocacy Center emphatically confirms that people with mental illness are responsible for only a small portion of violent events. Furthermore, violent actions by persons with mental illness are most frequently committed by those not receiving treatment. The center goes on to cite studies that establish an association between serious mental illness and a slightly increased propensity to acts of violence. One Scandinavian meta-analysis on the relationship between schizophrenia and violence found, for example, that “individuals with these diagnoses are associated with violence and violent offending”.

When it comes to the most publicized serious crime – mass shootings – some research indicates a relationship between mental illness and these events. A New York Times article first makes the argument that mass shooters are not “insane”. The article then cites research studies showing that 20 percent of mass shooters have been characterized as psychotic or delusional at the time of their crimes.

While the public at large is appropriately more concerned about the connection between mental illness and public safety, population health management companies such as Beacon Health Options are equally concerned about violence to self and access to lethal means of self-destruction. Suicides represent 61 percent of the 34,000 annual US gun deaths. Between 44 and 54 percent of gun-related suicides involve individuals with mental health conditions, the majority of whom were not currently receiving treatment for their condition. States that have enacted legislation restricting access to guns for at-risk persons report reduced fatalities.

Invitation for action

Given this sobering background data, we offer the following thoughts and takeaway considerations as a means to convert this knowledge to constructive solutions:

  1. Individuals with SMI are no more prone to committing violence than the general population, as the percentage of crimes they commit is commensurate with their representation of the general population; we should counter myth-based stigmatization with thoughtful, fact-based, assertive responses … repeatedly, until no longer necessary.
  2. Mental health conditions increase vulnerability to victimization; individual skill training for self-protection may be beneficial.
  3. Mental health conditions slightly increase the propensity to perpetrate violence for a small subset of individuals; we cannot afford to ignore warning signs, and we need to provide both treatment and containment when indicated.
  4. SUD conditions intensify the risk for committing violent crimes, with or without mental illness; we need to recognize the heightened risk and provide access to evidence-based SUD care.
  5. Effective mental health treatment reduces the likelihood of any given individual enacting violent behavior; however, treatment alone is not a magic remedy and continued monitoring and support are indicated for individuals with a history of violence.
  6. Although controversial, an increasing number of states have enacted extreme risk protection order or “red flag” laws, temporarily removing access to lethal firearms for at-risk individuals due to mental illness. These laws, which include due process, effectively limit access to lethal means and increase access to psychiatric care.
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