US Politics Mega-thread - Page 1735

The Contested Relationship between Violence and Mental Illness

Although proposed OPC (outpatient commitment) statutes tap into public fear about the potential for violence among persons with mental illness, serious violent acts by persons with severe mental illness are uncommon. Major psychiatric conditions like schizophrenia and mood disorders, by themselves, contribute relatively little—about 4%—to the overall risk of interpersonal violence in the population, and most perpetrators of commonplace violent acts do not have serious psychopathology. Studies indicate that although there is a slightly elevated risk of violence in persons with severe mental illness, such serious acts are still rare. The factors that contribute to violence in the mentally ill are often as varied and complex as those in the general population. In fact, it has been demonstrated that persons with mental illness are more frequently subjected to physical or sexual victimization, and these experiences compounded by other psychosocial factors may increase the risk of violence perpetration in these populations.

A study of patients with mental illness found that the factors associated with violence included a history of violent victimization, homelessness, cohabitation, exposure to community violence, substance abuse, poor mental health status, and a history of psychiatric hospitalisation. None of these risk factors, alone, explained an elevated risk, and patients with one or none of these risk factors had violence risks equal to that of the general population without mental illness. Addition of a second risk factor doubled the risk of violence, and those with 3 or more risk factors were most likely to be violent, indicating that the risks for violent behaviour are multifactorial and compounded by social factors throughout the life course.

However, the prospect of a violent act by a person with a severe mental illness generates grave public concern and fear, which is often compounded by media coverage of these acts. Clinicians are faced with increasing legal liability and responsibility for the actions and behaviours of their inadequately treated or noncompliant patients, adding to concerns about the risk of violence among their patients. Such concerns negatively affect the care of a disenfranchised population while stoking an existing stigma and fear surrounding mental illness. These patients are often high users of services often requiring involuntary commitment, but psychiatrists are often limited in their ability to care for these patients due to lack of sufficient intensive outpatient services.

Some of the controversy over OPC involves the potential for violence by persons with severe mental illness and how inflated views of violence potential fuels stigmatizing views of mental illness. Attitude surveys in the United States reliably document the popular belief that mental illness ‘causes’ violence and the strong correlation of this belief with public endorsement of the use of legal mandates to require treatment adherence. Drawing on public opinion, political advocates of OPC in recent years have ‘sold’ OPC by capitalizing on the publicity surrounding sensational acts of violence by people with mental disorders—explicitly promoting involuntary outpatient treatment as a needed measure to ensure public safety. But even proponents of OPC express caution about OPC’s public safety promise. Indeed, the recent resource document on OPC developed by the American Psychiatric Association states, “The goal of involuntary outpatient commitment is to mobilise appropriate treatment resources, enhance their effectiveness and improve an individual’s adherence to the treatment plan. Involuntary outpatient commitment should not be considered as a primary tool to prevent acts of violence” (emphasis added by the article). Despite these cautions about assigning OPC the task of violence prevention, the recent scourge of mass shootings in the United States have led many US lawmakers, wary of the powerful gun lobby, to implicate mental illness as the chief cause of gun violence in the United States.