The National Alliance on Mental Illness (NAMI) recently commissioned a poll from Harris Interactive regarding public awareness of and attitudes towards schizophrenia.
Here are some of the findings, pulled from the NAMI report:
Two million Americans are living with schizophrenia (1% of the nation's population age 18 or older). NAMI notes that this is twice the number of people living with HIV/AIDS.
With medication, the symptoms of schizophrenia can often be controlled successfully. About 50% of those diagnosed with the illness can improve significantly or recover completely over time. However, only a third of those living with schizophrenia actually receive treatment, and there is an enormous delay, averaging 8.5 years, between when someone first experiences symptoms and when he/she receives treatment.
People mistake, overemphasize, or underestimate certain symptoms of schizophrenia. The greatest misconception (64%) is that "split or multiple personalities" are symptoms of schizophrenia. Symptoms such as drug abuse (24%), alcohol abuse (23%), insomnia (41%), and disorganized speech (35%) are also not widely recognized.
Violent behavior as a symptom was selected by 60% of the public, which represents a fundamental fault line in how Americans view schizophrenia and other mental illnesses. Ironically, most individuals with schizophrenia are not prone to violence; they typically withdraw from social interaction and simply prefer to be left alone.
The U.S. Surgeon General reported ten years ago that although some research exists to support public concern, "the overall likelihood of violence is low" and the "overall contribution of mental disorders to the total level of violence in society is exceptionally small." The "greatest risk" is from persons dually diagnosed with both a mental illness and a substance abuse disorder. There is also a "small elevation of risk" for persons with severe disorders such as psychosis, "especially if they are noncompliant with their medication."
Other studies support the U.S. Surgeon General's basic assessment and the National Institute of Mental Health (NIMH) has noted that substance abuse "always increases violent behavior, regardless of the presence of schizophrenia." Meanwhile, people with serious mental illnesses are as many as ten times more likely to be victims of violence than the general public.
[Editor's Note: Professor Dorean Marguerite Koenig, a member of the ABA's Task Force on Mental Disability and the Death Penalty and a Professor of Law at the Thomas M. Cooley Law School, notes that schizophrenia is by far the most common mental disorder seen in capital defendants.]
The vast majority of Americans recognize that schizophrenia is an illness (85%) and that with ongoing care, people diagnosed with schizophrenia can lead independent lives (79%).
But only one-fourth (24%) of the general public consider themselves to be familiar with the illness. In a list of 11 common medical conditions that included heart disease, cancer, diabetes, and depression, only Lou Gehrig's disease and multiple sclerosis ranked lower than schizophrenia in familiarity.
***
For more information and to read the full report, visit http://www.nami.org/.
Showing posts with label violence. Show all posts
Showing posts with label violence. Show all posts
Tuesday, June 10, 2008
Monday, June 9, 2008
Research on Rates of Violence Among Those with Severe Mental Illness
Here's an op-ed that appeared today in the Wall Street Journal by E. Fuller Torrey, the founder of the Treatment Advocacy Center (TAC). TAC is a national nonprofit organization dedicated to eliminating barriers to the timely and effective treatment of severe mental illnesses. TAC promotes laws, policies, and practices for the delivery of psychiatric care and supports the development of innovative treatments for and research into the causes of severe and persistent psychiatric illnesses, such as schizophrenia and bipolar disorder.
Compassion, Compulsion and the Mentally Ill
"The debacle of deinstitutionalization continues to worsen with each passing year. In 1955, there were 559,000 individuals in America's state mental hospitals. By 2005, there were only 47,000 state hospital beds left in the country, a number that continues to fall. Numerous studies have documented the tragic effects of releasing hundreds of thousands of seriously mentally ill individuals from state hospitals while failing to ensure that they receive treatment.
The latest, carried out by Jason Matejkowski and colleagues at the University of Pennsylvania, found that individuals with serious mental illnesses are responsible for 10% of all homicides in Indiana. That translates into approximately 1,700 out of 17,034 total homicides in the U.S. in 2006. Over the past 20 years – during which time the public mental-health system has progressively deteriorated – that would mean 38,000 of 388,311 total homicides.
The University of Pennsylvania study examined the records of 723 individuals convicted of homicide between 1990 and 2002 in the Hoosier state. The results were published in the Journal of the American Academy of Psychiatry and the Law.
Examples of such homicides include Joseph Corcoran, diagnosed with paranoid schizophrenia, who shot four people in Fort Wayne because he thought they were talking about him. And Frank Salyers, also diagnosed with paranoid schizophrenia, who killed a policeman in Goshen after his parents tried unsuccessfully to get treatment for him at a local mental-health facility.
Although the Indiana study is the largest research of its kind in the U.S., two earlier but smaller studies reported that seriously mentally ill individuals were responsible for 10% of homicides in Contra Costa County, Calif., and 29% of homicides in Albany County, N.Y.
Most of these homicides were preventable, since the perpetrators in most cases were not being treated. Nontreatment, a past history of violent behavior and substance abuse are strong predictors of potential dangerousness in this population. We have proven options for decreasing such violence, including outpatient commitment. These programs require mentally ill individuals at high risk for violence to continue taking medication as a condition for living in the community.
Kendra's Law, passed in New York state in 1999, established one such program. A 2005 study by the New York State Office of Mental Health showed that physical acts of violence – as well as suicide attempts and arrests – by patients compelled to undergo treatment under Kendra's Law dropped dramatically in just six months; a similar reduction in violent behavior was shown in a North Carolina study.
Despite such data, assisted outpatient treatment is seldom used in the 42 states in which it is available and does not even exist in the other eight states. Even in New York, only a few counties use Kendra's Law widely. Why not? One reason is the reluctance of mental-health professionals to mandate treatment, even for patients with a history of violence and noncompliance with treatment.
Another is the misconception that such programs are expensive. In fact, it is our failure to use such laws that is expensive. Repeated hospital readmissions, incarceration costs, and the costs of homicides and other associated violence take a far greater toll on local, state and federal coffers.
The societal cost of not treating the seriously mentally ill is staggering. They constitute at least one-third of the homeless population. Unable to defend themselves because of their disabilities, they are often exploited and victimized. Approximately 5,000 commit suicide each year – one-sixth of all suicides. An estimated 230,000 are in jails and prisons, 10% of all incarcerations.
According to a 2006 study by the U.S. Justice Department, 56% of state prisoners, 45% of federal prisoners and 64% of local jail inmates suffer from mental illnesses. In fact, there are now more individuals with a serious mental illness in state prisons than in state mental hospitals.
In the end, involuntarily treating people with serious mental illnesses – who, because of their illnesses, are not aware they are sick – does not infringe on their civil rights. The fears of civil libertarians notwithstanding, the paramount civil right of someone who is severely mentally ill should be adequate treatment.
As Supreme Court Justice Anthony Kennedy wrote in 1999: 'It must be remembered that for the person with severe mental illness who has no treatment, the most dreaded of confinements can be the imprisonment inflicted by his own mind, which shuts reality out and subjects him to the torment of voices and images beyond our powers to describe.'"
Dr. Torrey is the author, most recently, of "The Insanity Offense: How America's Failure to Treat the Seriously Mentally Ill Endangers Its Citizens," out this month by W. W. Norton.
Compassion, Compulsion and the Mentally Ill
"The debacle of deinstitutionalization continues to worsen with each passing year. In 1955, there were 559,000 individuals in America's state mental hospitals. By 2005, there were only 47,000 state hospital beds left in the country, a number that continues to fall. Numerous studies have documented the tragic effects of releasing hundreds of thousands of seriously mentally ill individuals from state hospitals while failing to ensure that they receive treatment.
The latest, carried out by Jason Matejkowski and colleagues at the University of Pennsylvania, found that individuals with serious mental illnesses are responsible for 10% of all homicides in Indiana. That translates into approximately 1,700 out of 17,034 total homicides in the U.S. in 2006. Over the past 20 years – during which time the public mental-health system has progressively deteriorated – that would mean 38,000 of 388,311 total homicides.
The University of Pennsylvania study examined the records of 723 individuals convicted of homicide between 1990 and 2002 in the Hoosier state. The results were published in the Journal of the American Academy of Psychiatry and the Law.
Examples of such homicides include Joseph Corcoran, diagnosed with paranoid schizophrenia, who shot four people in Fort Wayne because he thought they were talking about him. And Frank Salyers, also diagnosed with paranoid schizophrenia, who killed a policeman in Goshen after his parents tried unsuccessfully to get treatment for him at a local mental-health facility.
Although the Indiana study is the largest research of its kind in the U.S., two earlier but smaller studies reported that seriously mentally ill individuals were responsible for 10% of homicides in Contra Costa County, Calif., and 29% of homicides in Albany County, N.Y.
Most of these homicides were preventable, since the perpetrators in most cases were not being treated. Nontreatment, a past history of violent behavior and substance abuse are strong predictors of potential dangerousness in this population. We have proven options for decreasing such violence, including outpatient commitment. These programs require mentally ill individuals at high risk for violence to continue taking medication as a condition for living in the community.
Kendra's Law, passed in New York state in 1999, established one such program. A 2005 study by the New York State Office of Mental Health showed that physical acts of violence – as well as suicide attempts and arrests – by patients compelled to undergo treatment under Kendra's Law dropped dramatically in just six months; a similar reduction in violent behavior was shown in a North Carolina study.
Despite such data, assisted outpatient treatment is seldom used in the 42 states in which it is available and does not even exist in the other eight states. Even in New York, only a few counties use Kendra's Law widely. Why not? One reason is the reluctance of mental-health professionals to mandate treatment, even for patients with a history of violence and noncompliance with treatment.
Another is the misconception that such programs are expensive. In fact, it is our failure to use such laws that is expensive. Repeated hospital readmissions, incarceration costs, and the costs of homicides and other associated violence take a far greater toll on local, state and federal coffers.
The societal cost of not treating the seriously mentally ill is staggering. They constitute at least one-third of the homeless population. Unable to defend themselves because of their disabilities, they are often exploited and victimized. Approximately 5,000 commit suicide each year – one-sixth of all suicides. An estimated 230,000 are in jails and prisons, 10% of all incarcerations.
According to a 2006 study by the U.S. Justice Department, 56% of state prisoners, 45% of federal prisoners and 64% of local jail inmates suffer from mental illnesses. In fact, there are now more individuals with a serious mental illness in state prisons than in state mental hospitals.
In the end, involuntarily treating people with serious mental illnesses – who, because of their illnesses, are not aware they are sick – does not infringe on their civil rights. The fears of civil libertarians notwithstanding, the paramount civil right of someone who is severely mentally ill should be adequate treatment.
As Supreme Court Justice Anthony Kennedy wrote in 1999: 'It must be remembered that for the person with severe mental illness who has no treatment, the most dreaded of confinements can be the imprisonment inflicted by his own mind, which shuts reality out and subjects him to the torment of voices and images beyond our powers to describe.'"
Dr. Torrey is the author, most recently, of "The Insanity Offense: How America's Failure to Treat the Seriously Mentally Ill Endangers Its Citizens," out this month by W. W. Norton.
Thursday, February 28, 2008
Stop Criminalizing the Mentally Ill
That's the title of this week's column by Dr. María Félix-Ortiz ("Society, and judges, should stop criminalizing the mentally ill," San Antonio Express-News, February 26, 2008). Dr. Félix-Ortiz reinforces the fact that people with mental illness are not inherently prone to violence; in reality, they are more likely to be the victims of crime. She also provides suggestions for outpatient treatment and other preventative programs.
"Recent comments made by Judge Tom Rickhoff of Probate Court 2 to KSAT evening news (Feb. 15), suggest a need for educating our criminal justice community about severe mental illness. I was not surprised by his recognition of a problem, but quite disappointed by his proposed solutions.
The judge's comments reminded me of what might happen if you ask a carpenter to fix your sink: He's likely to address the problem with the tool he uses most, his hammer. But that hammer is likely to cause bigger problems for those rusty pipes.
Bipolar disorder is not a crime; it is a disorder of the brain. Few people who are mentally ill ever commit a violent crime; the rate is similar to that found in the general population. If we did an analysis of the number of people who have diabetes who committed violent crimes, we might want to fingerprint every one of these people as soon as they're diagnosed (and close all the ice cream parlors across town).
However, people with mental illness are two and a half times more likely to be victimized (raped, mugged, etc.) than are any of us in the general population. Dr. Virginia Hiday at North Carolina State University-Raleigh also found that court-ordered involuntary outpatient treatment (OPC) for at least six months was associated with dramatically lower incidents of violence among those who were mentally ill and had a history of violence.
Other studies have found intensive case management another effective way of reducing violence and increasing adherence to the treatment plan. Case management involves old-fashioned social work where the mental health professional visits the individual at home to monitor his or her adherence to the treatment plan, help him or her make connections with other services and offer the support that can really keep people healthy.
While somewhat costly, intensive case management and OPC can reduce the more costly expenses of law enforcement, criminal justice and hospitalizations.
If Judge Rickhoff wants some real solutions, why not consult with mental health professionals and advocates, people who have the right tools in their toolbox for the job? We don't need to further criminalize mental illness; we do need more, and more diverse, mental health services and an approach that balances civil/human rights with the community's need for safety.
Contrary to popular opinion, the best mental health professionals can't reliably predict violent behavior; we can identify risk factors, but there is no test, no equation that accounts for all the variables involved in such a prediction. Lo siento, we can't read minds either.
Substance abuse is more strongly associated with violent behavior. We're in sore need of a variety of empirically validated public drug rehab programs, and I'd like to emphasize 'variety.' The programs shouldn't all be 'hammers.' Different people have different needs. Needs vary across age, gender (pregnant women need treatment, too) and sometimes culture.
If we need to find a scapegoat, let's not blame the ill for their illness. Rather, we might ask our legislators why Texas spends only $38 per person on mental health when most states spend about $80 per person, and Washington, D.C., spends more than $400 per person."
"Recent comments made by Judge Tom Rickhoff of Probate Court 2 to KSAT evening news (Feb. 15), suggest a need for educating our criminal justice community about severe mental illness. I was not surprised by his recognition of a problem, but quite disappointed by his proposed solutions.
The judge's comments reminded me of what might happen if you ask a carpenter to fix your sink: He's likely to address the problem with the tool he uses most, his hammer. But that hammer is likely to cause bigger problems for those rusty pipes.
Bipolar disorder is not a crime; it is a disorder of the brain. Few people who are mentally ill ever commit a violent crime; the rate is similar to that found in the general population. If we did an analysis of the number of people who have diabetes who committed violent crimes, we might want to fingerprint every one of these people as soon as they're diagnosed (and close all the ice cream parlors across town).
However, people with mental illness are two and a half times more likely to be victimized (raped, mugged, etc.) than are any of us in the general population. Dr. Virginia Hiday at North Carolina State University-Raleigh also found that court-ordered involuntary outpatient treatment (OPC) for at least six months was associated with dramatically lower incidents of violence among those who were mentally ill and had a history of violence.
Other studies have found intensive case management another effective way of reducing violence and increasing adherence to the treatment plan. Case management involves old-fashioned social work where the mental health professional visits the individual at home to monitor his or her adherence to the treatment plan, help him or her make connections with other services and offer the support that can really keep people healthy.
While somewhat costly, intensive case management and OPC can reduce the more costly expenses of law enforcement, criminal justice and hospitalizations.
If Judge Rickhoff wants some real solutions, why not consult with mental health professionals and advocates, people who have the right tools in their toolbox for the job? We don't need to further criminalize mental illness; we do need more, and more diverse, mental health services and an approach that balances civil/human rights with the community's need for safety.
Contrary to popular opinion, the best mental health professionals can't reliably predict violent behavior; we can identify risk factors, but there is no test, no equation that accounts for all the variables involved in such a prediction. Lo siento, we can't read minds either.
Substance abuse is more strongly associated with violent behavior. We're in sore need of a variety of empirically validated public drug rehab programs, and I'd like to emphasize 'variety.' The programs shouldn't all be 'hammers.' Different people have different needs. Needs vary across age, gender (pregnant women need treatment, too) and sometimes culture.
If we need to find a scapegoat, let's not blame the ill for their illness. Rather, we might ask our legislators why Texas spends only $38 per person on mental health when most states spend about $80 per person, and Washington, D.C., spends more than $400 per person."
Tuesday, February 26, 2008
"Mentally ill unfairly portrayed as violent"
That's the title of an editorial that appeared yesterday in The Boston Globe, by Dr. Ronald Pies, a clinical professor of psychiatry at Tufts University. Dr. Pies cites several studies that illustrate the link (or lack thereof) between mental illness and violent behavior. Here are a few excerpts:
"Writing in the Nov. 16, 2006, New England Journal of Medicine, Dr. Richard A. Friedman of the Weill Cornell Medical College notes that only about 3 to 5 percent of violence in the general population is attributable to those with 'serious mental illness,' conventionally defined as schizophrenia, major depression, or bipolar disorder. The combined lifetime prevalence of these conditions in the US general population is estimated at 19 percent - far larger than their contribution to violence. ..."
"A 1980s study from the National Institute of Mental Health found, using community surveys, that individuals with schizophrenia, major depression, or bipolar disorder were two to three times as likely as those without these illnesses to commit acts of violence. However, to put this in perspective, substance abusers had more than twice the rate of violence as those with these serious mental illnesses.
Moreover, the study found that the vast majority of individuals with serious mental illness were not violent: The lifetime prevalence of violence among people with schizophrenia, major depression, or bipolar disorder was 16 percent, versus 7 percent among people without a mental illness. Those with anxiety disorders had no increased risk of violence.
Even more reassuring is the 1998 MacArthur Violence Risk Assessment Study, led by John Monahan and Henry Steadman, now of Policy Research Associates, which advocates for better mental health services. Unlike the NIMH study, which surveyed people randomly in the community, the MacArthur study evaluated psychiatric patients recently discharged from the hospital. And unlike the NIMH study, which relied solely on self-reports of violence, the MacArthur study used a combination of self-reports, collateral informants, and police and hospital records.
The MacArthur study found that the prevalence of violence among discharged psychiatric patients without a substance abuse disorder was similar to that among community-dwellers who didn't abuse substances. Furthermore, violence by these discharged patients rarely involved vicious attacks on strangers or clinicians. Usually, it resembled violence committed by other community-dwellers, such as hitting a family member inside the home. Lethal violence among the discharged patients was very rare.
In the February 2008 issue of Psychiatric Services, Monahan and Steadman conclude: '. . . for people [with mental illness] who do not abuse alcohol and drugs, there is no reason to anticipate that they present greater risk than their neighbors.'
That said, mental disorders do increase susceptibility to substance abuse, and thus indirectly increase risk of violence. Moreover, as Eric Elbogen of University of North Carolina Chapel Hill School of Medicine wrote me in an e-mail, '. . . a subgroup of people with mental illness likely uses alcohol and drugs to 'self-medicate' psychiatric symptoms.' In my experience, this behavior may reflect the inadequate, fragmented care often provided to those with mental illness who also abuse drugs or alcohol so-called "dual diagnosis" patients.
The image of the violent mentally ill person must also be tempered by research from Linda A. Teplin, of Northwestern University. Teplin finds that those with mental illness are much more likely to be victims than perpetrators of a violent crime. Among psychiatric outpatients, about 8 percent reported committing a violent act, whereas about 27 percent reported being the victim of a violent crime."
"Writing in the Nov. 16, 2006, New England Journal of Medicine, Dr. Richard A. Friedman of the Weill Cornell Medical College notes that only about 3 to 5 percent of violence in the general population is attributable to those with 'serious mental illness,' conventionally defined as schizophrenia, major depression, or bipolar disorder. The combined lifetime prevalence of these conditions in the US general population is estimated at 19 percent - far larger than their contribution to violence. ..."
"A 1980s study from the National Institute of Mental Health found, using community surveys, that individuals with schizophrenia, major depression, or bipolar disorder were two to three times as likely as those without these illnesses to commit acts of violence. However, to put this in perspective, substance abusers had more than twice the rate of violence as those with these serious mental illnesses.
Moreover, the study found that the vast majority of individuals with serious mental illness were not violent: The lifetime prevalence of violence among people with schizophrenia, major depression, or bipolar disorder was 16 percent, versus 7 percent among people without a mental illness. Those with anxiety disorders had no increased risk of violence.
Even more reassuring is the 1998 MacArthur Violence Risk Assessment Study, led by John Monahan and Henry Steadman, now of Policy Research Associates, which advocates for better mental health services. Unlike the NIMH study, which surveyed people randomly in the community, the MacArthur study evaluated psychiatric patients recently discharged from the hospital. And unlike the NIMH study, which relied solely on self-reports of violence, the MacArthur study used a combination of self-reports, collateral informants, and police and hospital records.
The MacArthur study found that the prevalence of violence among discharged psychiatric patients without a substance abuse disorder was similar to that among community-dwellers who didn't abuse substances. Furthermore, violence by these discharged patients rarely involved vicious attacks on strangers or clinicians. Usually, it resembled violence committed by other community-dwellers, such as hitting a family member inside the home. Lethal violence among the discharged patients was very rare.
In the February 2008 issue of Psychiatric Services, Monahan and Steadman conclude: '. . . for people [with mental illness] who do not abuse alcohol and drugs, there is no reason to anticipate that they present greater risk than their neighbors.'
That said, mental disorders do increase susceptibility to substance abuse, and thus indirectly increase risk of violence. Moreover, as Eric Elbogen of University of North Carolina Chapel Hill School of Medicine wrote me in an e-mail, '. . . a subgroup of people with mental illness likely uses alcohol and drugs to 'self-medicate' psychiatric symptoms.' In my experience, this behavior may reflect the inadequate, fragmented care often provided to those with mental illness who also abuse drugs or alcohol so-called "dual diagnosis" patients.
The image of the violent mentally ill person must also be tempered by research from Linda A. Teplin, of Northwestern University. Teplin finds that those with mental illness are much more likely to be victims than perpetrators of a violent crime. Among psychiatric outpatients, about 8 percent reported committing a violent act, whereas about 27 percent reported being the victim of a violent crime."
Read the full editorial.
Thursday, February 7, 2008
Mental Illness and Violence
The February 2008 issue of Psychiatric Services focuses on mental illness and violence. It includes such articles as "Perpetration of Violence, Violent Victimization, and Severe Mental Illness: Balancing Public Health Concerns," "Jail Incarceration, Homelessness, and Mental Health: A National Study," and "Risk of Violence by Psychiatric Patients: Beyond the "Actuarial Versus Clinical" Assessment Debate."
According to editor Howard Goldman, M.D., PhD., the issue "addresses behavioral extremes perpetrated by people with a mental disorder but more often perpetrated against them—by individuals and by society. ..."
Here's more from Dr. Goldman:
"Our field often focuses on the tension between personal liberty and societal protection. It is imperative that we get the balance right. The articles, brief reports, and commentaries in this issue address this set of concerns—the risk of violence and victimization, the proper role for seclusion and restraint and patients' preferences in regard to these practices, and rates of incarceration and homelessness and efforts to prevent these outcomes. At every turn there is the chance that we will underreact and there will be harm—or more likely, that we will overreact and a different kind of harm will result. I believe that we have an obligation to use extreme measures in the rarest of instances, when there is no alternative. When we exploit the dangers associated with mental illness to advance policy, we risk the harm of exploiting the individuals themselves."
"Psychiatric Services" is a publication of the American Psychiatric Association. You can read abstracts for the contents of this issue at http://psychservices.psychiatryonline.org/current.dtl#THIS_MONTH_S_HIGHLIGHTS.
According to editor Howard Goldman, M.D., PhD., the issue "addresses behavioral extremes perpetrated by people with a mental disorder but more often perpetrated against them—by individuals and by society. ..."
Here's more from Dr. Goldman:
"Our field often focuses on the tension between personal liberty and societal protection. It is imperative that we get the balance right. The articles, brief reports, and commentaries in this issue address this set of concerns—the risk of violence and victimization, the proper role for seclusion and restraint and patients' preferences in regard to these practices, and rates of incarceration and homelessness and efforts to prevent these outcomes. At every turn there is the chance that we will underreact and there will be harm—or more likely, that we will overreact and a different kind of harm will result. I believe that we have an obligation to use extreme measures in the rarest of instances, when there is no alternative. When we exploit the dangers associated with mental illness to advance policy, we risk the harm of exploiting the individuals themselves."
"Psychiatric Services" is a publication of the American Psychiatric Association. You can read abstracts for the contents of this issue at http://psychservices.psychiatryonline.org/current.dtl#THIS_MONTH_S_HIGHLIGHTS.
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