Monday 24 October 2016

Mental illness does not increase risk of violence

Patricia Casey

Published 28/06/2016 | 02:30

Senseless killing: Jo Cox (Picture: Yui Mok/PA Wire )
Senseless killing: Jo Cox (Picture: Yui Mok/PA Wire )

This has not been a good time for psychiatry as the link between mental illness and violence has once again been questioned. The massacre in Orlando has been linked to, among other things, the possible mental instability of the perpetrator Omar Mateen. This was based on claims regarding his violence from his first wife. Subsequently it was alleged that the personality assessment carried out by his employer was reported as normal by a psychologist, who then said she did no such assessment on this man. It emerges now that this was an administrative error and that another psychologist carried out the evaluation.

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Then the stabbing of Jo Cox, the British MP, also focused attention on mental illness. Thomas Mair, the man arrested and charged with her murder, is reported as having been on antidepressants, having had psychotherapy and according to reports, was in contact with a voluntary mental health organisation in an agitated state recently. And here in Ireland we just learned that a man who killed his parents in Donegal in 2014 had a diagnosed mental illness and may not have been taking treatment at the time.

A constellation of events such as these can induce safety panic. But more importantly, they reinforce the images of 'madness' and 'insanity' associated with the asylums of old. These are of gothic horror proportions. William Hogarth, the 18th-century British painter, is one of the best-known artists to focus on mental illness. For him, mental illness was a vice that was captured best in his collection known as The Rake's Progress. The continuing stigma and discrimination against those with mental illness stems largely from these caricatures of the assumed causal connection between mental illness and violence.

What is our current state of knowledge about the relationship between violence and mental illness? We should remember that most crimes are not committed by those with mental illness but by those who have no connection with the mental health services. Clearly some people with acute episodes of psychiatric illness may become violent and assaultive - I have seen it and nearly been the victim on more than one occasion, particularly when assessing patients in hospital emergency departments. Every psychiatrist in training and all our psychiatric nurses are trained in 'control and restraint techniques' and in 'breakaway techniques'. Yet we also know most definitely that most of the aggression in our emergency departments is caused, not by those who attend with mental illness, but by those who have problems linked to illicit drugs or alcohol misuse.

Research into the putative link between mental illness and violence confirms that our fears are exaggerated when compared to the danger from other sources. So the most up-to-date studies show that of itself mental illness is not a strong predictor of violence.

A very large study of over 34,000 adults by the National Institute of Alcohol Abuse and Alcoholism in 2008, showed that the best predictors of violence were being male, divorced, abusing substances and being unemployed. Other studies have added a chaotic personal environment coupled with poor personal supports and untreated mental illness.

Combining studies in what is called a 'meta-analysis' is another approach. One such study on psychiatric illness and violence was published in 2009 in the most prestigious psychiatric journal - The Archives of General Psychiatry. The authors showed that a person with severe mental illness who was not abusing substances and had no history of violence was at no greater risk of being violent in the following three years than anybody else in the general population.

So the current position is that, of itself, mental illness does not increase the risk of violence to others unless it is untreated or is associated with substance misuse. A history of violence or child abuse, youth, being male and having an unpredictable environment with few social supports are other risk factors, and these are the very same risk factors that are linked to aggression in the general population.

So, we need to self-check our biases and prejudices if we are to be fair to all. Those with mental illnesses are a vulnerable group who are already disadvantaged by poor psychiatric services and by the impact of their illness.

It would be unconscionable if prejudice and ignorance compounded this.

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