1. Home>
2. Specialties>
3. Psychiatry>
4. Summary and Comment

Are Psychiatric Patients Really Dangerous?

Substance use and history of violence play important roles in a patient’s risk for violent behavior.

A national survey found that 75% of respondents believed that people with mental illnesses are dangerous. Dramatic acts by people with serious psychiatric illnesses, such as the Virginia Tech shooter, can reinforce this belief. Using data from a two-wave diagnostic-interview study of 34,653 civilians (interviews conducted 2–4 years apart), researchers examined the possible relation between specific diagnoses (interview-based diagnosis of major depression, bipolar disorder, or substance abuse or dependence [SA/D]; or self-reported schizophrenia), and later violent behavior.

Remarkably, 42% of respondents in the first wave had one or more diagnoses (11% with schizophrenia, bipolar disorder, or major depression only; 21% with SA/D only; 9% with a mental disorder plus SA/D). Risk for violence between the first and second waves was significantly elevated among those with a mental disorder plus SA/D or histories of violence, but not among subjects with mental illness alone. The greatest increase was found in individuals with mental illness, SA/D, and previous violence, who had a 10-fold greater risk than did those with mental illness only. Numerous historical factors independently predicted violence by the second wave, including past violence; juvenile detention; childhood physical abuse; recent divorce, unemployment, or victimization; and parental history of criminality.

Comment: Lack of independent corroboration of violent behavior in this study probably led to underestimates of its occurrence, and the prevalence of mental disorders was alarmingly high. Nevertheless, the data suggest that mental illness alone does not usually lead to violent behavior unless the patient also has a substance use disorder or history of violence. Undoubtedly, some non–substance-using psychotic individuals are dangerous because of delusions or command hallucinations, but they appear to be in the minority, although such individuals might not have been included in this outpatient population. Clinicians assessing dangerousness in their patients should evaluate factors that increase violence risk, such as recent losses or victimization and personal and family history.

— Steven Dubovsky, MD

Published in Journal Watch Psychiatry March 16, 2009

Citation(s):

Elbogen EB and Johnson SC. The intricate link between violence and mental disorder: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry 2009 Feb; 66:152.

• Original article (Subscription may be required)
• Medline abstract (Free)