“Despite an inclination to seek simplicity, violence is a large, complex problem, and we have to keep its many parts in mind at the same time,” Mark Rosenberg, M.D., M.P.P., told an Institute of Medicine (IOM) workshop on mental health and violence in late February in Washington, D.C.
“Mental illness plays only a small role in violence, but that intersection is clouded by misconceptions and disinformation in the public’s mind,” said Rosenberg, co-chair of the IOM’s Forum on Global Violence Prevention and president and CEO of the Task Force for Global Health in Decatur, Ga.
Forum attendees heard presentations by three dozen researchers and advocates seeking points of early intervention to reduce violence against self and others.
The recent wave of mass shootings, often attributed to individuals with mental illness, should be placed in perspective, said Thomas Insel, M.D., director of the National Institute of Mental Health. “Most people with mental illness are not violent, and most acts of violence are not committed by people with mental illness,” said Insel in his keynote address. “People with untreated psychotic illness are at increased risk of irrational behavior, including violence, especially directed at family and friends. This usually happens at the onset of illness and before diagnosis or treatment. However, once treatment starts, these people have no higher risk of violence than the general population and are more often victims of crime.”
Homicide rates have declined dramatically (from 9.8/100,000 to 4.8/100,000) over the last two decades, Insel noted. Mass shootings are still rare events, however, compared with the ordinary daily toll of violence.
“There were 32 dead at Virginia Tech, but there are also 32 suicides a week today on college campuses,” Insel pointed out. “We should be more concerned with suicide. Violence is more often self-directed.”
There are 38,000 suicides per year in the United States, compared with 14,000 homicides. Ninety percent of the suicides are committed by people with a mental illness, compared with just 5 percent of the homicides, he said.
Suicide may outweigh homicide as a cause of violent death, but its prevalence is very likely underestimated, said Eric Caine, M.D., a professor and chair of psychiatry at the University of Rochester and co-director of the Center for the Study of Prevention of Suicide at the University of Rochester Medical Center.
“Self-poisoning with opiates or alcohol has skyrocketed,” said Caine. “We call them ‘unintentional,’ but we don’t know how to determine intent.”
Caine presented county-by-county maps of the United States showing the geographic and cultural patterns of violent death. Homicide is a more urban phenomenon, while suicide has a more rural distribution, overlapping strongly with motor-vehicle injuries and those unintentional poisonings, he noted.
“How you end up dying is less the issue than how you get to dying,” he said. “Some people die one way, some people die another way, but they may share many common risks.”
Those common risks include early childhood adversity, exposure to trauma, and family and community turmoil, he said. “So we need to start working early with families and children and communities.”
How preventable is violence?
“Both homicide and suicide are difficult to predict on the individual level,” said Insel. “Means restriction works, and treatment can reduce violence, especially suicide.”
The nation also could do a better job of caring for people with untreated psychosis, he said. Now it takes about 110 weeks to get someone into treatment, a figure Insel would like to cut to 12 weeks, in part by detecting prodromes and intervening early.
In addition, better public-health surveillance, better tools for prevention, and better individual predictors of risk and resilience would help reduce suicide, he said.
More research within the field will help, but so will broader educational efforts. “The fear of those with mental illness confounds the assessment of risk, but early detection and early treatment can reduce risk,” Insel stated.
“We need to bring this issue to the public with passion, clarity, and data,” said Rosenberg. “Keeping science in the forefront will not be easy, but when people understand, they can bring about change.” ■