Perpetration of violence, violent victimization, and severe mental illness: balancing public health concerns

OBJECTIVE: This review examined U.S. empirical studies published since 1990 of the perpetration of violence and of violent victimization among persons with severe mental illness and their relative importance as public health concerns. METHODS: MEDLINE, PsycINFO, and Web of Science were searched for published empirical investigations of recent prevalence or incidence of perpetration or victimization among persons with severe mental illness. Studies of special populations were included if separate rates were reported for persons with and without severe mental illness. RESULTS: The search yielded 31 studies of violence perpetration and ten studies of violent victimization. Few examined perpetration and victimization in the same sample. Prevalence rates varied by sample type and time frame (recall period). Half of the studies of perpetration examined inpatients; of these, about half sampled only committed inpatients, whose rates of perpetration (17%-50%) were higher than those of other samples. Among outpatients, 2% to 13% had perpetrated violence in the past six months to three years, compared with 20% to 34% who had been violently victimized. Studies combining outpatients and inpatients reported that 12% to 22% had perpetrated violence in the past six to 18 months, compared with 35% who had been a victim in the past year. CONCLUSIONS: Perpetration of violence and violent victimization are more common among persons with severe mental illness than in the general population. Victimization is a greater public health concern than perpetration. Ironically, the discipline's focus on perpetration among inpatients may contribute to negative stereotypes.     

Victimization and perpetration of intimate partner violence and substance use disorders in a nationally representative sample

ABSTRACT: The aim of this study was to examine the relationship between perpetration and victimization of physical and sexual intimate partner violence (IPV) in the past year and substance use disorders (SUDs) in the past year, including alcohol, sedatives/tranquilizers, cocaine, cannabis, and nicotine stratified according to sex. Data were from the National Epidemiologic Survey on Alcohol and Related Conditions. A series of adjusted logistic regression models were conducted. Among men and women, all types of SUDs were associated with increased odds of IPV perpetration (odds ranging from 1.4 to 8.5 adjusting for sociodemographic variables). IPV victimization increased the odds of having all types of SUDs for male and female victims, with the exception of sedatives/tranquilizer abuse/dependence among women (odds ranging from 1.5 to 6.0 adjusting for sociodemographic variables). Substances that had the most robust relationship with perpetration and victimization of IPV included alcohol and cannabis, after adjusting for sociodemographic variables, mood disorders, anxiety disorders, personality disorders, and mutual violence.     

Risk of Future Offense Among Probationers with Co-occurring Substance Use and Mental Health Disorders

The criminal justice system is the primary service delivery system for many adults with drug and alcohol dependence, mental health, and other health service needs. The purpose of this study was to examine the relationship between risk of future offense, mental health status and co-occurring disorders in a large substance abuse diversion probationer population. A purposive sample of 2,077 probationers completed an assessment to screen for mental health disorders, substance use disorders, risk of future crime and violence, and several demographic characteristics. Probationers who screened positive for co-occurring substance use and mental health disorders were significantly more likely to be at higher risk of future crime and violence compared to probationers who screened positive for only substance use, only a mental health disorder, or no substance use or mental health disorder. Implications for substance use and mental health service delivery are discussed, and recommendations are made for further research.     

Violent victimization of persons with co-occurring psychiatric and substance use disorders

OBJECTIVE: This study examined the frequency with which persons in the community with psychiatric disorders, substance use disorders, and both types of disorders are victims of violence. METHODS: The relationship between diagnosis, gender, and victimization over a one-year period was examined in two cross-sectional data sets, one drawn from a study of adaptation to community life of persons with severe mental illness in Connecticut (N=109) and the other drawn from assessments made by caseworkers in a Connecticut outreach project for persons with psychiatric and substance use disorders (N=197). Analysis of variance was used to evaluate the frequency of victimization across diagnostic categories in each data set. RESULTS: People with co-occurring psychiatric and substance use disorders had significantly more episodes of victimization than those with either a psychiatric or a substance use disorder only. Gender was not associated with victimization. Qualitative data from focus groups indicated that social isolation and cognitive deficits leading to poor judgment about whom to trust may leave people with serious mental illness vulnerable to drug dealers. CONCLUSIONS: Social environmental mechanisms, such as exploitation by drug dealers, may play an important role in maintaining victimization among persons with co-occurring disorders.     

Intimate Partner Violence Victimization and Perpetration by Puerto Rican Women with Severe Mental Illnesses

Previous research indicates a higher prevalence of victimization among severely mentally ill women. Few studies have either compared these levels across diagnostic categories or evaluated perpetration by the women. We report qualitative and quantitative findings regarding intimate partner violence perpetrated both against and by a sample of 53 Puerto Rican women diagnosed with major depression, bipolar disorder, or schizophrenia. Interviewers shadowed participants for a period of 2 years. Two-thirds of the women with serious mental illness had histories of victimization. However, 23% of the women also reported histories of violence towards their significant others. This was attributed to various reasons, such as anger, revenge, control, and self-defense. Participants described their personal conceptualization of the violence they received and perpetrated. This has implications for programs designed to prevent family violence, for health care professionals in general, and for psychiatrists, who may be called upon to address future risk of victimization or commission of violence.     

Factors Influencing the Frequency of Emergency Department Utilization by Individuals with Substance Use Disorders

This study assessed the characteristics of individuals with substance use disorders (ISUDs) according to their frequency of emergency department (ED) utilization, and examined which variables were associated with an increase in ED visits using Andersen’s model. Data linkage of administrative databanks from three sources [addiction rehabilitation centre registry, physician billing systems, and hospital discharge databank] for 4526 ISUDs was performed. Predisposing, enabling and need factors associated with number of ED visits were determined using a negative binomial regression model and generalised estimating equations. The rate of ED utilization for this population was 9.6 %. Increased number of ED visits was associated with the following variables: older age, social fragmentation, number of consultations with general practitioners, number of consultations with psychiatrists, number of consultations with other types of physicians, alcohol abuse, drug abuse, schizophrenia, anxiety disorders, personality disorders, co-occurring substance dependence and mental disorders, co-occurring substance dependence and chronic physical disorders, and co-occurring mental health disorders and chronic physical disorders. By contrast, a diagnosis of substance dependence, co-occurring drug and alcohol abuse, and a co-occurring diagnosis of substance dependence with mental health and chronic physical disorders decreased ED visits. Efforts to reduce avoidable use of EDs should focus on chronic-disease management and other related strategies aimed at reinforcing services to ISUDs in the community, especially for ISUDs with a co-occurring diagnosis of either mental health disorders or chronic physical disorders.     

Mental disorders and violence in a total birth cohort: results from the Dunedin Study

BACKGROUND: We report on mental disorders and violence for a birth cohort of young adults, regardless of their contact with the health or justice systems. METHODS: We studied 961 young adults who constituted 94% of a total-city birth cohort in New Zealand, April 1, 1972, through March 31, 1973. Past-year prevalence of mental disorders was measured using standardized DSM-III-R interviews. Past-year violence was measured using self-reports of criminal offending and a search of official conviction records. We also tested whether substance use before the violent offense, adolescent excessive perceptions of threat, and a juvenile history of conduct disorder accounted for the link between mental disorders and violence. RESULTS: Individuals meeting diagnostic criteria for alcohol dependence, marijuana dependence, and schizophrenia-spectrum disorder were 1.9 (95% confidence interval [CI], 1.0-3.5), 3.8 (95% CI, 2.2-6.8), and 2.5 (95% CI, 1.1-5.7) times, respectively, more likely than control subjects to be violent. Persons with at least 1 of these 3 disorders constituted one fifth of the sample, but they accounted for half of the sample's violent crimes (10% of violence risk was uniquely attributable to schizophrenia-spectrum disorder). Among alcohol-dependent individuals, violence was best explained by substance use before the offense; among marijuana-dependent individuals, by a juvenile history of conduct disorder; and among individuals with schizophrenia-spectrum disorder, by excessive perceptions of threat and a history of conduct disorder. CONCLUSIONS: In the age group committing most violent incidents, individuals with mental disorders account for a considerable amount of violence in the community. Different mental disorders are linked to violence via different core explanations, suggesting multiple-targeted prevention strategies.     

Treatment for co-occurring mental and substance use disorders in five state Medicaid programs

OBJECTIVES: This study described the locations and patterns of psychiatric and substance abuse treatment for Medicaid beneficiaries with co-occurring mental and substance use disorders in five states. METHODS: Medicaid beneficiaries aged 21 to 65 with psychiatric or substance use disorders were identified with claims and encounter records. Groups were further divided into those with and those without a diagnosed substance use disorder. Adjusted odds of treatment in community-based settings, inpatient facilities, emergency departments, and hospital outpatient departments were calculated. RESULTS: A total of 92,355 persons had a psychiatric disorder, 34,158 had a substance use disorder, and 14,256 had co-occurring psychiatric and substance use disorders. In all five states, beneficiaries with severe mental illness (schizophrenia, bipolar disorder, or major depression) and a substance use disorder had higher odds of inpatient, emergency department, and hospital-based outpatient psychiatric treatment, compared with those with severe mental illness alone. In four of five states, both severe and less severe mental illness and a co-occurring substance use disorder were associated with lower odds of community-based treatment compared with those with the respective mental illness alone. Compared with those with less severe mental illness alone, individuals with less severe psychiatric disorders and a co-occurring substance use disorder had higher odds of inpatient treatment in all states and of emergency department use in three of five states. Odds of inpatient and outpatient hospital use and emergency department use for substance abuse treatment were higher for persons with severe mental illness and a co-occurring substance use disorder in most states, compared with odds for those with a substance use disorder alone. CONCLUSIONS: Heavy inpatient and emergency department use by Medicaid beneficiaries with co-occurring substance use disorders is a consistent cross-state problem. Co-occurring disorders may decrease the likelihood of community-based treatment for those with less severe mental disorders and for those with severe mental illness, suggesting that policies focusing only on these settings may miss a significant proportion of people with these co-occurring disorders.     

A national survey of care for persons with co-occurring mental and substance use disorders

OBJECTIVE: The delivery of appropriate treatment to persons who have mental and substance use disorders is of increasing concern to clinicians, administrators, and policy makers. This study sought to describe use of appropriate mental health and comprehensive substance abuse care among adults in the United States with probable co-occurring disorders. METHODS: Data from the Healthcare for Communities survey, which is based on a national household sample studied in 1997 and 1998, were used to identify individuals who had probable co-occurring mental and substance use disorders. The sociodemographic and clinical characteristics of these individuals and their use of services were recorded. Logistic regression analysis was used to identify variables associated with receipt of mental health and substance abuse treatment and with receipt of appropriate treatment. RESULTS: Estimates for the U.S. adult population based on the weighted survey data indicated that 3 percent of the population had co-occurring disorders. Seventy-two percent did not receive any specialty mental health or substance abuse treatment in the previous 12 months; only 8 percent received both specialty mental health care and specialty substance abuse treatment. Only 23 percent received appropriate mental health care, and 9 percent received supplemental substance abuse treatment. Perceived need for treatment was strongly associated with receipt of any mental health care and with receipt of appropriate care. CONCLUSIONS: Despite the availability of effective treatments, most individuals who had co-occurring mental health and substance use problems were not receiving effective treatment. Efforts to improve the care provided to persons who have co-occurring disorders should focus on strategies that increase the delivery of effective treatment.     

Substance Use and Five-Year Survival in Washington State Mental Hospitals

This report combines five-year survival and cause of death in individuals discharged from Washington State mental hospitals with (1) mental illness only, (2) co-occurring mental illness and substance use disorder, or (3) substance use disorder only. Five-year survival was similar in the three groups, although after adjusting for age, individuals with co-occurring disorders or substance use disorder were almost 50% more likely to die than those with mental illness only. Persons with these conditions need treatment to prevent premature death and medical conditions directly related to substance use disorder.     

Past violence and substance use disorder and subsequent violence towards others: six year analysis of the Assaulted Staff Action Program (ASAP)

Recent research has begun to document evidence of associations between past violence toward others, untreated personal victimization, and substance use disorder and later acts of violence toward others. This appears true for many types of individuals, including psychiatric patients who have been victims of violence. This six-year retrospective study sought to evaluate these possible associations in assaultive psychiatric patients. Data were gathered in the context of the Assaulted Staff Action Program (ASAP), a crisis intervention program for staff victims of patient assault. Both histories of violence (violence toward others and/or personal victimization) and substance use disorder in assaultive psychiatric patients were individually and jointly examined and found to be associated with subsequent assaults by these patients. Increased levels of both past violence toward others, personal victimization, and substance use disorder were associated with the largest increased frequency of subsequent assault. The implications and possible links to emergency mental health services are discussed [International Journal of Emergency Mental Health, 2(4), 241-247].     

The relationship of gambling to intimate partner violence and child maltreatment in a nationally representative sample

It has been suggested that family violence is associated with gambling problems. However, to date, this relationship has not been thoroughly investigated using representative data. The purpose of the current study was to analyze the relationship between gambling problems and the perpetration and victimization of intimate partner violence (including dating and marital violence) and child maltreatment (including minor child assault and severe child abuse) using nationally representative data. Data were drawn from the US National Comorbidity Survey Replication (n = 3334; 18 years and older). Multiple logistic and multinomial logistic regression models were used to examine the relationships between gambling and the perpetration and victimization of dating violence, marital violence, and child maltreatment. The results indicated that problem gambling was associated with increased odds of the perpetration of dating violence (Adjusted Odds Ratios (AORs) ranged from 2.2 to 4.2), while pathological gambling was associated with increased odds of the perpetration of dating violence (AORs ranged from 5.7 to 11.9), severe marital violence (AOR = 20.4), and severe child abuse (AOR = 13.2). Additionally, dating violence, marital violence, and severe child abuse victimization were associated with increased odds of gambling problems. The results were attenuated when adjusted for lifetime mental disorders. These findings can be used as evidence-based research to inform healthy public gambling polices and inform prevention and intervention efforts.     

Prevalence, patterns, and correlates of co-occurring substance use and mental disorders in the United States: variations by race/ethnicity

ObjectiveThis study examines racial/ethnic differences in the prevalence, patterns, and correlates of co-occurring substance use and mental disorders (COD) among Whites, Blacks, Latinos, and Asians using data from the Collaborative Psychiatric Epidemiology Studies.MethodWe first estimated the prevalence of various combinations of different co-occurring depressive and anxiety disorders among respondents with alcohol, drug, and any substance use (alcohol or drug) disorders in each racial/ethnic group. We then estimated the prevalence of different patterns of onset and different psychosocial correlates among individuals with COD of different racial/ethnic groups. We used weighted linear and logistic regression analysis controlling for key demographics to test the effect of race/ethnicity. Tests of differences between specific racial/ethnic subgroups were only conducted if the overall test of race was significant.ResultsRates of COD varied significantly by race/ethnicity. Approximately 8.2% of Whites, 5.4% of Blacks, 5.8% of Latinos, and 2.1% of Asians met criteria for lifetime COD. Whites were more likely than persons in each of the other groups to have lifetime COD. Irrespective of race/ethnicity, most of those with COD reported that symptoms of mental disorders occurred before symptoms of substance use disorders. Only rates of unemployment and history of psychiatric hospitalization among individuals with COD were found to vary significantly by racial/ethnic group.ConclusionsOur findings underscore the need to further examine the factors underlying differences between minority and nonminority individuals with COD as well as how these differences might affect help seeking and utilization of substance abuse and mental health services.     

Using Information Technology to Evaluate the Detection of Co-Occurring Substance Use Disorders Amongst Patients in a State Mental Health System: Implications for Co-Occurring Disorder State Initiatives

The current study describes a system-wide method of evaluating detection strategies for co-occurring disorders within a state mental health system. Information technology was used to merge administrative datasets from the New Jersey mental health and substance abuse systems and identify individuals treated in both systems. We measured a 53% detection rate of substance use disorders amongst adult patients in the mental health system with particularly low detection rates in acute settings (49.0%) and among female (43.7%), older (36.2%), and psychotic patients (43.6%). The methodology described here could help evaluate critical aspects of ongoing state co-occurring disorder quality improvement initiatives. This paper was presented at the 2005 American Psychiatric Association Annual Meeting (May 21–26, 2005) in Atlanta, Georgia.     

A longitudinal investigation of intimate partner violence among mothers with mental illness

OBJECTIVE: Severe mental illness, substance use, and intimate partner violence have emerged as major intersecting public health problems that adversely and disproportionately impact the lives of women in the United States. This longitudinal study investigated the demographic and clinical correlates of intimate partner violence in a sample of 324 mothers with severe mental illness. METHODS: A secondary analysis of longitudinal data was conducted by using multiple logistic regression. Participants were part of a longitudinal, community-based study of mothers with severe mental illness, which was aimed at understanding how these mothers viewed motherhood. The women were interviewed initially at baseline (interviews were conducted between 1995 and 1996) and then about 20 months later at follow-up (interviews were conducted between 1997 and 1998). RESULTS: At follow-up the prevalence rate of intimate partner violence was 19%. Multiple logistic regression analyses showed a significant positive relationship between alcohol and drug misuse at baseline and intimate partner violence at follow-up, indicating that women with a co-occurring diagnosis of a substance use disorder (dual diagnosis) were more likely than women without such a diagnosis to report intimate partner violence. The number of lifetime psychiatric hospitalizations and the number of symptoms related to psychiatric disability exhibited at baseline were positively associated with intimate partner violence at follow-up, and age was inversely associated with intimate partner violence. CONCLUSIONS: Mental health professionals serving mothers with mental health problems need to be aware of and prepared to assess the significant correlation between these intersecting public health problems in order to influence successful interventions. Particular attention must be given to the special treatment needs related to dual diagnosis and victimization and the impact of these factors on this vulnerable population.     

Economic grand rounds: types of practitioners and outpatient visits in a private managed behavioral health plan

Types of privately insured outpatient treatment provided by in-network practitioners were examined in a national managed behavioral health care organization to consider how practitioner type and expertise are related to diagnoses of mental disorders, substance use disorders, or both. Using 2004 practitioner credentialing, patient enrollment, and claims data, the investigators found that two-thirds of claims for psychiatrists involved medication management and two-thirds also involved psychotherapy (an overlap of about 30%). Most patients with substance use disorders saw practitioners who had specialized alcohol or drug disorder training. Claims for patients with more complex co-occurring mental and substance use disorders indicate utilization of appropriately qualified practitioners with substantial experience on average.     

Improving mental health service responses to domestic violence and abuse

Abstract

Domestic violence and abuse is a considerable international public health problem, which is associated with mental disorders in both women and men. Nevertheless, victimization and perpetration remain undetected by mental health services. This paper reviews the evidence on mental health service responses to domestic violence, including identifying, referring, and providing care for people experiencing or perpetrating violence. The review highlights the need for mental health services to improve rates of identification and responses to domestic violence and abuse, through the provision of specific training on domestic violence and abuse, the implementation of clear information sharing protocols and evidence-based interventions, and the establishment of care referral pathways. This review also highlights the need for further research into mental health service users who perpetrate domestic violence and abuse.     

Gender differences in violence exposure and violence risk among adolescent inpatients

Gender-specific rates of violence exposure and violence perpetration among psychiatrically ill adolescents has received little scientific attention. We examined 130 adolescent inpatients and found no difference between male and female subjects with respect to self-reported violence potential or actual violence perpetration. Female inpatients, however, were significantly more often victims of sexual assault, and male inpatients were significantly more often victims of physical assault. For male inpatients, a history of violence perpetration in one area was closely linked with a history of violence victimization in the same area. Alternatively, patterns of victimization and perpetration among female inpatients were less predictable and had crossover to victimization and perpetration experiences in other areas. Correlational analyses revealed that violence risk was associated with a broad range of internalizing and externalizing psychopathology. Significant associations with hopelessness, suicidality, and childhood trauma differentiated the violence risk of male and female inpatients. We propose a hypothesis for understanding these differences and conclude that although psychiatrically ill adolescent male and female patients may commonly fall victim to differing forms of violence, both genders are at equal risk for actual violence perpetration.     

Violence and violent victimization in people with severe mental illness in a rural low-income country setting: A comparative cross-sectional community study

BackgroundViolence perpetrated by and against people with severe mental illness (SMI) is important but rarely investigated in low- and middle income countries.ObjectiveTo compare the prevalence of perpetrated violence and violent victimization, and associated factors, in people with and without SMI in rural Ethiopia.MethodA random sub-sample of people with a standardized, clinician diagnosis of SMI (n = 201) was recruited from an existing population-based study and compared to a group of unaffected individuals from the same neighborhood (n = 200). The lifetime and 12-month prevalence of violence and violent victimization was measured using an adapted version of the McArthur Violence Interview.ResultLifetime and 12-month prevalence of perpetrated violence in people with SMI (28.4% and 17.4%, respectively) was significantly higher than in the non-mentally ill comparison group (15.0% and 8.5%, respectively). Male gender, being literate and violent victimization were associated independently with violence in both groups. In people with SMI, violence was associated additionally with being unmarried, exposure to stressful life events and non-response to medication. The prevalence of violent victimization was also significantly higher in people with SMI than those without SMI (60.7% vs. 41.5%). In people with SMI, violent victimization was associated with unemployment, non-adherence to treatment and being a perpetrator of violence.ConclusionsOur finding of high levels of violence and violent victimization in people with SMI underscores the need to improve access to mental health services in this setting, as well as the urgent need to raise awareness about victimization of people with SMI.