Study Highlights Role of Triggers in Short-Term Risk of Violence

Most individuals with mental illness are not violent, but a study published Wednesday in JAMA Psychiatry that examined triggers that increase short-term risk of violence highlights the importance of incorporating a violence risk assessment into psychiatric evaluations.

Seena Fazel, M.D., a professor of forensic psychiatry at the University of Oxford, United Kingdom, and coauthors used nationwide Swedish data for individuals born between 1958 and 1988 to examine a range of triggers for violent crimes in patients with psychotic disorders and individuals without a psychiatric diagnosis. The study sample included 34,903 patients who were diagnosed with schizophrenia spectrum disorders, 29,692 patients with bipolar disorder, and more than 2.7 million people who had never been diagnosed with a psychiatric disorder.

Within each subsample, the authors identified people who had experienced any of the following triggers for violent acts: exposure to violence, parental bereavement, self-harm, traumatic brain injury, unintentional injuries, and substance intoxication. The risk of the individual committing a violent crime in the seven days following exposure to a trigger was then compared with risk in earlier periods when they were not exposed to any trigger. (Violent crime was defined as a conviction for homicide, assault, robbery, threats and violence against an officer, unlawful threats, unlawful coercion, kidnapping, illegal confinement, arson, intimidation, or sexual offenses.)

All three groups showed statistically significant associations between each of the six triggers and the rate of violent crime in the week after exposure compared with earlier control periods. Although the absolute risk of violence was greatest in patients with schizophrenia, the relative risks across the three groups was similar, with the exception of parental bereavement, where the authors found stronger relative risks in the patients with schizophrenia (adjusted odds ratio [aOR], 5.0) than in the controls (aOR, 1.7).

“This study demonstrates that violence risk occurs when there are certain triggers, especially substance intoxication and severe stress. This is true whether or not an individual suffers from a mental disorder,” APA Immediate Past President Renée Binder, M.D., a professor of psychiatry and director of the Psychiatry and Law Program at the University of California, San Francisco School of Medicine, told Psychiatric News.

However, interpreting what the findings say about patients with psychotic disorders is more difficult, due to the fact that the authors of the study looked only at diagnoses, not the effect of treatment on modifying risks, she continued.

“The key point in assessing violence risk is not necessarily the diagnosis. Patients who have been diagnosed with schizophrenia or bipolar disorder and who are in remission and are complying with treatment are not at risk for violence. Thus, it is not the diagnosis per se, but rather the stage of illness (acute versus chronic), the treatment status, and whether or not the person is using substances” that are important when evaluating risk of violence in a psychiatric evaluation, she said. 

“Clinically, these findings imply that patients with schizophrenia or bipolar disorder should receive a psychiatric assessment for the risk of violence if they sustain an experience similar to one of the triggers tested in this study,” Jan Volavka, M.D., Ph.D., of the New York University School of Medicine, wrote in a related editorial. “The need for assessment is particularly pressing for young patients who have been targets of violence. To be useful, the assessment should occur as soon as possible after the event; certainly within the first week. Depending on the results, the patient may need supportive psychotherapy, medication adjustment, or hospitalization. In general, the findings raise the need to treat comorbid substance use disorders in individuals with schizophrenia and bipolar disorder.”

For related information, see the APA resource document “Psychiatric Risk Assessment,” of which Binder is a coauthor, and the Psychiatric Services article “Proximal Risk Factors forShort-Term Community Violence Among Adults With Mental Illnesses.”

(Image: Olimpik/Shutterstock)

38-Year Study Assesses Violence and Premature Mortality in People With Schizophrenia

People with schizophrenia and related disorders have increased rates of suicide, premature mortality, and convictions for violent offenses, according to a report from British and Swedish researchers published Tuesday in Lancet.

The study compared 24,297 Swedish patients with their unaffected siblings and matched controls from the general population, assessing outcomes from 1972 through 2009. Within five years of diagnosis, 13.9% of male patients and 4.7% of female patients recorded one of those three adverse outcomes. Overall, those adverse outcomes were 7.5 times more likely compared with men in the general population and 11.1 times more likely for women, wrote Seena Fazel, M.D., an honorary consultant forensic psychiatrist in the University of Oxford’s Department of Psychiatry, and colleagues.

The authors assessed adverse outcomes in all three study groups and found that three risk factors present in all three cohorts predicted the adverse outcomes: drug use disorders, criminality, and self-harm. "Schizophrenia and related disorders are associated with substantially increased rates of violent crime, suicide, and premature mortality," they concluded. "Risk factors for these three outcomes included both those specific to individuals with schizophrenia and related disorders, and those shared with the general population. Therefore, a combination of population-based and targeted strategies might be necessary to reduce the substantial rates of adverse outcomes in patients with schizophrenia and related disorders."

"[T]he authors suggest that to best manage violence and suicide risk, we should perhaps now turn our attention to those factors evident across populations," added Eric Elbogen, Ph.D., an associate professor, and Sally Johnson, M.D., a professor of psychiatry at the University of North Carolina, in a related commentary. "In this way, we might not only reduce actual risk in people with schizophrenia, but appropriately place this in the context of violence reduction for society as a whole. The potential to achieve practical, evidence-based, and potentially less stigmatising interventions is one of the most exciting implications of this study."

To read more research on violence risk in those with schizophrenia, see the Psychiatric News articles, "Antisocial Behavior Raises Violence Risk in Some Psychosis Patients" and "Untreated Schizophrenia Increases Risk for Violence By Inmates." Also see "Systematic Suicide Risk Assessment for Patients With Schizophrenia: A National Population-Based Study" in Psychiatric Services.

(Image: blade tucker/Shutterstock.com)

Study Finds Link Between Traumatic Brain Injury and Premature Death

People who experienced a traumatic brain injury (TBI) were three times more likely to die prematurely than were matched control subjects, according to a study based on medical and population records of more than 2 million people in Sweden. The study, headed by Seena Fazel, M.D., a senior research fellow in the Department of Psychiatry at the University of Oxford in England, was published online today in JAMA Psychiatry.

The individuals were born in 1954 or later, and medical records covered the 40 years from 1969 to 2009. Within that group, 218,300 incurred TBIs, and 2,378 (1.1%) died at least six months or more after their injury. TBI was an independent risk factor for premature mortality, half of which was due to “external causes”—injuries, suicide, or assault. About 61 percent of those with TBI who died prematurely had lifetime substances abuse or other psychiatric diagnoses.

Yet those diagnoses may not explain these early deaths, said Robert Robinson, M.D., a professor of psychiatry at the University of Iowa, in an accompanying editorial. "[O]ne of the most likely explanations for the findings in the current study is the existence of personality characteristics of impulsiveness, risk-taking behaviors, and proneness to substance abuse,” Robinson said. “These patients incur a TBI and continue to demonstrate these behaviors after the TBI, which ultimately leads to a fatality.”

To read more about traumatic brain injury and psychiatric issues, see the Psychiatric News article, “When Traumatic Brain Injury Is Complicated by Personality Disorders.” Also see the book Management of Adults With Traumatic Brain Injury from American Psychiatric Publishing.

(Image: Hxdbzxy/Shutterstock.com)