Mental Illness and Serious Harm to Others - University of Liverpool

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NHS National Programme on Forensic Mental Health Research and Development 1992). It may be, too, that in a treated sample, treatment has an effect. Another possibility may be real international or community differences. Although studies are stronger on correlates than causes of violence in the context of illness, there are some which do begin to disentangle cause and effect (Taylor, 1993; Taylor et al, 1994) and possible pathways (e.g. Steadman and Silver, 2000). There is good evidence that violent offending specifically is more likely than not to post-date the onset of illness (Taylor and Hodgins, 1994). 3.3 Contemporaneous substance misuse and other comorbidities Few doubt that through the 1990s, and maybe also the 1980s, alcohol and illicit drug use have been associated with higher rates of violence among people with mental illness, as it has among those without (Soyka, 2000), but there most certainty ends. Swanson et al (1990) may have been the first to advance epidemiological evidence from the community for the association, but most subsequent epidemiological studies concurred, regardless of jurisdiction. At about the same time that this evidence was emerging, it was also becoming apparent that people with schizophrenia were four times as likely to misuse such substances as their healthy peers, and people with mania six times as likely (Regier at al, 1990). Changed availability of substances of misuse may be one of the most important effects of the shift to community care of people with mental disorder, and could account for any changes in violence rates. Through the 1950s, ‘60s, and ‘70s, a number of independent studies in Europe and the USA had shown an inverse relationship between substance misuse and violence among people with schizophrenia (Häfner and Böker, 1973; Virkkunen, 1974; Tardiff and Sweillam, 1980; Taylor, 1993). Further, changes in fashion or availability of illicit drugs may lead to varying trends in association. The nature and extent of influence on behaviour is not equivalent between drugs. Tiihonen and Swartz (2000) provide perhaps the best framework for understanding or setting hypotheses about the interactions. They list: ❑ Substance abuse reduces impulse control. ❑ Substance abuse exacerbates psychotic and other symptoms. ❑ Substance abuse is a proxy measure for personality disorder. ❑ Medication side-effects lead to self-medication with illicit substances. ❑ Medication non-compliance leads to substance use. ❑ Psychotic and other symptoms lead to self-medication. ❑ Exposure to adverse social environments leads to substance use and aggressive behaviour. ❑ Boredom and lack of structure lead to substance use. There is no epidemiological evidence to support any one of these hypotheses over any other. Indeed, Tiihonen and Swartz plausibly suggest that the hypotheses are not mutually exclusive. They might be applied with advantage to test relative risks in each individual case. Mueser et al (1998b), in a review of aetiological theories, were unimpressed only with evidence for the self-medication model. Mueser and colleagues (1998a) have also summarised the problems of 'traditional' treatment approaches for people who have major mental disorder and substance abuse problems, and reviewed 9
NHS National Programme on Forensic Mental Health Research and Development studies of integrated treatment approaches. 3.4 Social context of violence with psychosis 'Woman, 32, pushed to her death by subway stranger' (Evening Standard, 5 January, 1999) This is perhaps the popular image of violence associated with mental illness - something that is lurking around the corner for any of us as an 'innocent’ victim. In fact, the Evening Standard had to trawl the world for this story to set beside the good news, set in smaller headlines and without pictures, that the contribution of people with mental disorder to national homicide statistics in the UK is falling (Taylor and Gunn, 1999). The subway stranger story was sufficiently unusual that it was still apparently the only such case and a focus for discussion at a conference on mentally disordered offenders in the home town, New York, over 18 months later. The National Confidential Inquiry into Homicide and Suicide (1999) offers further support in the UK not only of the small contribution to UK homicide figures of people with mental disorder, but for an inverse relationship between symptomatic mental illness and stranger killings. Irrational fear of 'mad strangers' has been accompanied by a belief that the development of a more ordinary sort of health care for people with mental disorder - generally delivered while they live in their homes and only sometimes in hospital on occasions of more serious illness episodes - has unleashed an upsurge of 'mad violence' in the community. Not so if the Australian experience is typical (and there is no reason to believe otherwise): occurrence of violence by people with schizophrenia has increased since the shift to community care in Victoria, but only to the same extent as it has risen within the general population (Mullen et al, 2000). This is an area, not peculiar to violence in the context of mental disorder, where the difference between public perception and media portrayals on the one hand, and reality on the other, is considerable. Moreover, diversion from the real risks could increase the risk of harm. For example, there is evidence that having a spouse or partner may be a good prognostic indicator in a general population, and in a criminal population with respect to offending and in a psychiatric one with respect to outcome for major mental disorder, perhaps particularly schizophrenia (Taylor, 1999). However, there is also evidence that intimates, including spouses and mothers, may be at particular risk of serious violence, in the context of schizophrenia. This is true in general psychiatric samples (Estroff et al, 1998) or serious offender-patient populations (Johnston and Taylor, submitted). Neither such relationships nor effective action to prevent violence against close family are, however, much studied. 3.5 Treatment studies If the illnesses per se, and in particular the symptoms of those illnesses, are even partly relevant to the violent acts among those few people who do become violent in this context, then it follows that effective treatment ought to be the mainstay of violence limitation and prevention. Neuroleptic medications have been shown unequivocally to be the most effective treatments for psychosis on a group basis, with a very high relapse 10
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