Public and professional attention in recent years has tended to focus on
whether people with mental illness are more likely than others to commit acts
of violence, but a new study suggests that violent victimization of
these individuals may be the greater public health problem.
A literature review of studies published since 1990 on the perpetration of
violence by, and violent victimization of, mentally ill individuals indicates
that victimization is considerably more common than perpetration.
The study was published in the February Psychiatric Services as
part of a special issue on violence and mental illness.
Among outpatients, 2 percent to 13 percent had perpetrated violence in the
prior six months to three years, compared with 20 percent to 34 percent who
had been violently victimized. Studies combining outpatients and inpatients
reported that 12 percent to 22 percent had perpetrated violence in the prior
six to 18 months, compared with 35 percent who had been a victim in the
"Although society may regard persons with mental illness as dangerous
criminals, our review of the literature shows that violent victimization of
persons with severe mental illness is a greater public health concern than
perpetration of violence," wrote lead author Linda Teplin, Ph.D., and
colleagues in their report.
Along with other reports examining issues associated with violence and its
relationship to mental illness, the study by Teplin and colleagues suggests
that that relationship—which has attracted the attention of
policymakers, professionals, and the general public—may be less
straightforward than typically thought.
The journal also includes a print "debate" between the authors
of the 1998 MacArthur Violence Risk Assessment Study and psychiatrist Fuller
Torrey, M.D., and attorney Jonathan Stanley, J.D., about the methodology and
interpretation of that report (see Findings of Landmark Study Still Provoke
This seminal report, which was published in the Archives of General
Psychiatry, has been cited by many advocates to show that individuals
with mental illness are not more likely than those in the general population
to commit acts of violence.
But Torrey and Stanley argued that such an interpretation has obscured the
real risks of violence associated with mental illness—especially
untreated mental illness—and claim that unpublished data from the study
would have shown the critical importance of treatment.
Their article appears in Psychiatric Services as a
point-counterpoint, with Torrey and Stanley's claims followed by responses
from MacArthur study authors John Monahan, Ph.D., and Henry Stedman, Ph.D.
Torrey is executive director of the Stanley Medical Research Institute and
president of the Treatment Advocacy Center, an organization that advocates for
laws permitting involuntary treatment of patients with severe mental
Another article in the journal, by Alec Buchanan, M.D., Ph.D., of Yale
University, showed that the ability of mental health professionals to predict
which patients are at risk to be violent has improved over the last 30
But the article by Jeffrey Swanson, Ph.D., pointed out that the accuracy of
even the best such screening test is substantially below what would be
considered acceptable in other areas of medicine, such as oncology.
He is a professor of psychiatry and behavioral sciences at Duke University
"Mental health professionals are concerned about the recovery of
individuals with mental disorders, and we must protect them from harm,"
Howard Goldman, M.D., Ph.D., editor of Psychiatric Services, wrote in
an accompanying editorial.
"But we also have an obligation to protect society from dangers that
might be associated with mental illness," Goldman continued."
Historically our society has been more concerned about its own
protection than about the protection of psychiatric patients. But it is
imperative that we get the balance right. We need a more nuanced view of the
association between violence and mental illness—and that is the
editorial intent behind this special issue."
Yet victimization appears to be a subject that has only rarely crossed the
minds of researchers: while there were 31 studies of violence perpetration by
people with mental illness, there were only 10 studies on victimization, and
few studies looked at both phenomena, according to the study by Teplin and
They searched MEDLINE, PsycINFO, and Web of Science publications for
empirical investigations of recent prevalence or incidence of perpetration or
victimization among persons with severe mental illness.
With regard to perpetration of violence, studies of inpatients with severe
mental illness show that perpetration of violence is most prevalent among
committed patients before hospitalization, when violence may have precipitated
Prevalence ranged from 14.2 percent among voluntary inpatients in the month
before hospitalization to 50.4 percent among committed inpatients in the four
months before hospitalization.
Only one study of adults in treatment for severe mental illness
investigated the incidence of recent violent victimization. That study, titled"
Crime Victimization in Adults With Severe Mental Illness: Comparison
With the National Crime Victimization Survey," was published in the
August 2005 Archives of General Psychiatry. Teplin and colleagues
examined 936 randomly selected persons with severe mental illness from a
random sample of treatment facilities—outpatient, day treatment, and
residential treatment—in Chicago.
There were 168.2 incidents of violent victimization per 1,000 persons per
year, more than four times the rate in the general population. Incidence
ratios remained statistically significant even after the analysis controlled
for sex and race/ethnicity.
All 10 studies on victimization examined prevalence of self-reported
victimization (including the Teplin study, which also reported incidence),
with prevalence varying from study to study by type of victimization and by
type of population sample. But irrespective of the type of sample and type of
victimization, prevalence was much higher in all studies than in the general
population, as found in the National Crime Victimization Study.
In this month's Psychiatric Services article, Teplin and
colleagues cited research pointing to a theoretical model whereby social
disorganization and poverty may increase a person's vulnerability to both
victimization and propensity to perpetrate violence.
"Repeated victimizations may lead to suspicion and mistrust, which in
turn may lead to conflictive and stressful situations—in short, a cycle
of victimization and perpetration," they wrote.
They argued for a new focus on victimization and on research that can help
disentangle the complex relationship between mental illness, violence
perpetration, and violent victimization.
"Ironically, the discipline's focus on the perpetration of violence
among inpatients may contribute to the negative stereotypes of persons with
severe mental illness, which are often based on the label of 'mental patient,'
not on observed behavior," they stated. "We must balance the dual
public health concerns of protecting the safety of the public and protecting
persons with severe mental illness from criminal victimization."
The FebruaryPsychiatric Servicesis posted
An abstract of "Crime Victimization in Adults With Severe Mental
Illness: Comparison With the National Crime Victimization Survey" is