Study tracks violence among mentally ill

According to national surveys, many people believe that individuals diagnosed with mental disorders are prone to violence. Now, the most comprehensive follow-up study to date of patients discharged from mental hospitals indicates that those who do not abuse alcohol or illicit drugs commit violent acts no more frequently than a random selection of their neighbors in urban communities.

 Discharged psychiatric patients and nonpatients who do exhibit signs of substance abuse have markedly higher rates of violence, reports a research team led by sociologist Henry J. Steadman of Policy Research Associates in Delmar, N.Y. Substance abuse was more widespread among the former patients, and in the first 10 weeks after discharge it showed a stronger link to violence in this group than in the neighborhood comparison group.

"Important distinctions can be made among discharged psychiatric patients in assessing which [of them] are at an increased risk of committing violent acts against others," Steadman says. "Whether patients are abusing alcohol or illegal drugs in the community turns out to be one of the key distinctions."

 Most violent acts carried out by former patients, as well as by their neighbors, were aimed at family members or friends and occurred at home.

"These findings clearly indicate that the public's fear of violence on the street by discharged psychiatric patients who are strangers to them is misdirected," contends study coauthor John Monahan, a psychologist at the University of Virginia in Charlottesville.

 The new report appears in the May Archives of General Psychiatry.

 Some earlier community studies, based solely on arrest records, found increased rates of violence among the mentally ill. However, researchers have noted that substance abuse often accompanies violent acts by individuals with or without psychiatric disorders.

 Steadman's team interviewed 951 people shortly after they had been admitted for brief stays in psychiatric facilities in Pittsburgh, Kansas City, and Worcester, Mass. Participants, who ranged in age from 18 to 40, included white, black, and Hispanic men and women.

 Their self-reports of violent behavior were gathered in interviews conducted every 10 weeks for the first year after their discharge. A family member or friend was also interviewed every 10 weeks about the former patient's behavior. Police and hospital records for each volunteer provided a third source of evidence.

 The comparison group, interviewed once about their violent behavior in the past 10 weeks, consisted of 519 people selected at random from the neighborhoods in which the Pittsburgh patients lived. Additional information came from interviews with family members or friends and from arrest records.

 Violent acts consisted of threats with weapons, physical assaults, and pushing or hitting that caused injuries.

 The proportion of patients who committed a violent act during the study year was 18 percent for those with a major mental disorder (such as schizophrenia or manic depression) who showed no signs of substance abuse, 31 percent for patients with both a major mental disorder and substance abuse, and 43 percent for patients with another mental condition (such as a personality disorder) and substance abuse.

 In Pittsburgh, non-substance-abusing patients and their community counterparts exhibited comparable violence rates.

 During the follow-up period, violence rates gradually fell among patients who abused drugs, the scientists note.

 These results "further challenge the dangerousness stereotype" attached to psychiatric patients, assert epidemiologists Bruce G. Link and Ann Stueve of Columbia University in an accompanying commentary.

 Community surveys directed by Link find a moderate association between violence and certain psychiatric symptoms-feelings of being controlled by external forces, having thoughts put into one's head, and being targeted for harm by others.

 Steadman's group plans to examine the relationship of specific mental symptoms to violence. The researchers will also compare violence rates among male and female patients.